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Textbook of Obstetrics
Sudha Salhan
SECTION 1: INTRODUCTION
CHAPTER 1:
Evolution of Obstetrics
DEFINITION OF OBSTETRICS
Historical Evolution
CHAPTER 2:
Medicolegal Aspects of Obstetrics
THE LEGAL CONTEXT OF PROFESSIONAL LIABILITY
CIVIL LAW IN RELATION TO OBSTETRIC PRACTICE
CRIMINAL LAW IN RELATION TO OBSTETRIC PRACTICE
MEDICOLEGAL ASPECTS OF MEDICAL TERMINATION OF PREGNANCY (MTPs) AND STERILISATION
ROUTINE ANTENATAL CARE
MEDICOLEGAL ASPECTS OF LOWER SEGMENT CAESAREAN SECTION (LSCS)
CHAPTER 3:
Bioethics
INTRODUCTION
PROFESSIONAL CODE FOR PHYSICIANS
EVOLUTION OF BIOETHICS
BIOMEDICAL RESEARCH ETHICS
Basic Principles
Advances in Science and Technology
Ethical Guidelines
Bioethics Education
CONCLUSION
Evidence-based Obstetric Practice
CHAPTER 4:
Communication and Counselling in Obstetrics
LISTENING AND LEARNING SKILLS
HELPFUL NON-VERBAL COMMUNICATIONS
Reflection and Paraphrasing
Validation
Empathise
BUILDING CONFIDENCE AND GIVING SUPPORT
Example
Recognise and Praise What a Patient is doing Right
Give Practical Help Wherever Possible
Give a Little, Relevant Information
Use Simple Language
Make One or Two Suggestions, Not Commands
Summarising
SUPPORT DURING EMERGENCY SITUATIONS IN OBSTETRICS
Maternal Mortality
Severe Maternal Morbidity
Intrauterine Death or Still Birth
Birth of a Baby with an Anomaly
Postpartum Depression
During Examination
PATIENTS RIGHTS CHARTER
SECTION 2: PHYSIOLOGY OF PREGNANCY
CHAPTER 5:
Physiology of Conception and Foetal Development
FERTILISATION
IMPLANTATION (NIDATION)
DEVELOPMENT OF EMBRYO AND FOETUS
EMBRYONIC DEVELOPMENT (FIG. 5.5)
FOETAL DEVELOPMENT (FIG. 5.7)
FOETAL CIRCULATION (Fig. 5.8)
In Utero
After Birth
FOETAL HORMONES
HUMAN SEX RATIO
CHAPTER 6:
Placenta, Umbilical Cord and Foetal Membranes
DEVELOPMENT OF PLACENTA
Development of Foetal Part of Placenta
Placental Membrane/Placental Barrier
Development of Maternal Part of Placenta (Fig. 6.5)
Important Points
Anatomy of Placenta
The Placental Attachment
Placental Perfusion
Placental Circulation (Fig. 6.10)
Ageing of Placenta
Function of the Placenta
Placental Transfer
Placental Transfer of Individual Substances
Respiratory Function
Nutritive Functions of Placenta
Excretory Function
Immunological Function
Endocrine Function of Placenta
Human Chorionic Gonadotrophins (hCG)
Functions of hCG
Human Placental Lactogen (hPL)
Functions
Other Placental Hormones
Progesterone
DEVELOPMENT OF UMBILICAL CORD (FIG. 6.13)
Contents of Umbilical Cord
Characteristic of the Cord
Insertion of Cord
Functions of the Umbilical Cord
THE FOETAL MEMBRANES (FIG 6.14)
Amnion
Chorion
Development of Amnion
The Amnion
Histogenesis of Amnionic Cells
Functions of Foetal Membranes
Amniotic Fluid
Amount of Amniotic Fluid
Composition of Amniotic Fluid
Functions and Clinical Importance of Amniotic Fluid
CHAPTER 7:
Immunology of Normal Pregnancy
BASICS OF REPRODUCTIVE IMMUNOLOGY
Adaptive Immune Response
T-Helper (TH) Cells
Theories for Immunotolerance of Pregnancy
Pregnant Uterus is an Immune Privileged Site
Systemic Immunosuppression
Lack of Expression of HLA Antigens on Trophoblast Cells
Blocking Antibodies and HLA Sharing
Cytokine Shift
Fas-fas Ligand System and Immune Tolerance
Natural Killer Cells (NKC)
Genome Alteration
Attachment to endometrium—Endometrial Sulphydral Groups and Pinopodes
Gaining Vascular Foothold—Vascular Endothelial Growth Factor (VEGF)
Burrowing within the Endometrium Matrix Metalloproteinases (MMP)
CHAPTER 8:
Maternal Adaptations
INTRODUCTION
ANATOMICAL CHANGES OF CONCEPTION
Uterus
Size
Shape
Position
Thickness
Uterine Musculature
Dextrorotation
Decidua
Contractility
Nerve Supply
Isthmus
Blood Supply
Cervix
Epithelium and Glands of Cervix and Cervical Canal
Cervical Mucus
Ovaries
Fallopian Tubes
Vagina, Vulva and Pelvic Floor
Ligaments, Parametrium and Peritoneum
Gastrointestinal System
Skeletal System
Skin
Neurological Changes
Abdominal Wall
Breasts
PHYSIOLOGICAL CHANGES OF CONCEPTION
Advantages of Increased Blood Volume are:
Metabolic changes
Coagulation Changes
Urinary System
Gastrointestinal System
Bone Changes
Changes in Endocrine Glands
CHAPTER 9:
Abnormalities of Placenta, Cord and Membranes
ANATOMY OF PLACENTA
Abnormalities of Placenta
Placenta Bipartite or Bilobate
Succenturiate Placenta: Incidence 5 per cent
Ring Shaped Placenta
Membranous Placenta or Placenta Diffusa
Fenestrated Placenta
Extrachorial Placenta
Large Placenta
Placenta Accreta, Placenta Increta and Placenta Percreta (Figs 9.5A to D)
Placental Infarcts
Abnormalities of Cord (Figs 9.6A and B)
Complications of Membranes
AMNIOCENTESIS
SECTION 3: PRENATAL CARE
CHAPTER 10:
Preconceptional Counselling
DEFINITION
PATIENT EVALUATION
Medical Disorders
Genetic Disorders
Previous Obstetric Outcome
Drugs and Vaccinations
Drugs
Nutrition
CHAPTER 11:
Diagnosis of Pregnancy
PRESUMPTIVE EVIDENCE OF PREGNANCY
Symptoms
Signs
PROBABLE EVIDENCE OF PREGNANCY
Changes in Shape, Size and Consistency of the Uterus
Hegar's Sign
Palmer's Sign
Abdominal Enlargement
Changes in the Cervix
Braxton Hick's Contractions
Ballottement
Outlining the Foetus
Detection of Chorionic Gonadotropins in Urine or Serum
POSITIVE SIGNS OF PREGNANCY
CHRONOLOGICAL APPEARANCE OF SPECIFIC SIGNS AND SYMPTOMS OF PREGNANCY
CHAPTER 12:
Prenatal Diagnosis and Foetal Therapy
INTRODUCTION
TERATOLOGY
TYPES OF BIRTH DEFECTS
AETIOLOGY OF MALFORMATIONS (FLOW CHART 12.2)
CONGENITAL ABNORMALITIES
High-risk Factors
Chromosome Constitution
PRE-IMPLANTATION GENETIC DIAGNOSIS (PGD)
SECTION 4: ANTENATAL CARE
CHAPTER 13:
Antenatal History Taking and Examination
INTRODUCTION
History taking
IDENTIFICATION AND DEMOGRAPHIC DATA
MENSTRUAL HISTORY
OBSTETRIC HISTORY
Terms Used
PRESENT OBSTETRIC HISTORY
PAST OBSTETRIC HISTORY
PAST MEDICAL HISTORY
FAMILY HISTORY
PERSONAL HISTORY
EXAMINATION
General Examination
Obstetric Examination
Inspection
Palpation
Obstetric Grips
Auscultation
Station
Pelvic Examination
CHAPTER 14:
Antenatal Screening
THE OBJECTIVES OF ANC
CRITERIA OF HIGH-RISK PREGNANCY
Past Pregnancy
INVESTIGATIONS DONE DURING PREGNANCY
Routine Investigations on First Visit
Specific Investigations
Screening for Rh Antibodies
Screening for Gestational Diabetes
Screening for Syphilis (Table 14.2)
Hbs Ag Testing
Maternal Serum Alpha-foetoprotein (MSAFP)
Triple Test
Quad Screening
Screening for Pre-eclampsia
Testing for Group B Streptococci
Papanicolaou Smear
Testing for HIV
Ultrasonography
Maternal Weight Gain During Pregnancy
MINOR AILMENTS OF PREGNANCY
Nausea and Vomiting
Constipation
Varicosities
Haemorrhoids
Leg Cramps
Urinary Frequency
Immunisation
ADVICE TO THE PREGNANT WOMEN
Exercise
Occupation
Travel
Footwear
Clothes
Teeth
Sexual Activity
Care of the Breasts
FOLLOW UP VISIT: USUAL ROUTINE (TABLE 14.4)
First Visit Before 12 Weeks
Second Visit Close to 26 Weeks
Third Visit at Around 30 Weeks
Fourth Visit at 36–38 Weeks
Weight Gain (Table 14.3)
Blood Pressure
Obstetric Examination
CHAPTER 15:
Antenatal Exercises
INTRODUCTION
Temperature of the Mother and the Foetus
Haemodynamic Effects of Exercise
Demand of Oxygen
Demand of Energy
Influence of Pregnancy on Exercise
Effect of Exercise in Labour Outcome
Absolute Contraindications
Relative Contraindications
Instructions to Patients
When to Stop Exercise Immediately
Permitted Exercises
Exercises not Allowed
Risk of Severe Exercises on the Mother
Posture for Relief of Pain
Exercises to be Practiced During Labour
During Contractions
During Delivery
CHAPTER 16:
Nutrition During Pregnancy and Lactation
INTRODUCTION
THE ROLE OF THE PLACENTA
MECHANISM OF PLACENTAL TRANSFER
NUTRITION OF THE MOTHER
ENERGY AND ENERGY NUTRIENTS DURING PREGNANCY
Protein
Carbohydrate
Fat
B Vitamin Associated with Energy and Protein Intake
Nutrients for Blood Production and Cell Growth
Nutrients for Bone Development
Other Nutrients
Fluid Requirements
Nutrient Supplements for Pregnant Women
Maternal Nutrition during Lactation
Water
Energy and Energy Nutrients
Vitamins and Minerals
Fat Soluble Vitamins
Water Soluble Vitamins
Minerals
CHAPTER 17:
Antepartum Foetal Surveillance
INTRODUCTION
Time of Starting Antenatal Surveillance
Indications for Antepartum Foetal Surveillance
Maternal Conditions
Pregnancy-related Conditions
Foetal Conditions
Routine Antepartum Surveillance
TECHNIQUES OF ANTEPARTUM FOETAL SURVEILLANCE
Foetal Movement Counts by the Mother
Methods of Assessment of Foetal Movement
Maternal Assessment of Foetal Activity
Further Evaluation if Daily Foetal Movement Record (DFMR) is Decreased
Nonstress Test (NST)
Vibroacoustic or Foetal Acoustic Stimulation Test (VAS)
Contraction Stress Test (CST)
Contraindications
CST Procedure
Interpretation of CST
Nipple Stimulation Test
Biophysical Profile (BPP)
Foetal Neurodevelopment
Sequence of Foetal Deterioration
Technique of Manning's Biophysical Profile (BPP) Scoring
Clinically Significant Points
Interpretation of BPP (Table 17.2)
Modified Biophysical Profile (MBPP)
Umbilical Artery and Ductus Venosus Doppler Velocimetry
Doppler Ultrasound
Foetal Lung Maturation Tests
How often should antepartum surveillance be performed?
MANAGEMENT
RECOMMENDATIONS
SECTION 5: EARLY PREGNANCY COMPLICATION
CHAPTER 18:
Bleeding in Early Pregnancy
VAGINAL BLEEDING
Obstetric Causes
Nonobstetric Causes
Implantation Bleeding
Miscarriage
Spontaneous Miscarriage
Incidence
Aetiology
Types of Spontaneous Miscarriage
PATHOLOGY OF SPONTANEOUS MISCARRIAGE
Threatened Miscarriage
Management of Threatened Miscarriage
CLINICAL EXAMINATION
Per Speculum Examination
Pelvic Examination (per vaginal examination)
Investigations
Treatment
Follow-up
Prognosis
Inevitable Miscarriage
Management
First Trimester
Follow-up
Incomplete Miscarriage
Investigations—Same as in Inevitable Miscarriage
USG Findings
Management
Examination
Per Speculum Examination
Pelvic Examination
USG Finding
Management
MISSED MISCARRIAGE
Definition
Carnaceous Mole
Clinical Features
On Examination
Pelvic Examination
Investigations
Ultrasound Findings
Management
Lab Investigations
SURGICAL PROCEDURES
Category I
Category II
Follow-up
Blighted Ovum
Septic Miscarriage
Ectopic Pregnancy
HYDATIDIFORM MOLE
Introduction
Incidence
EPIDEMIOLOGY AND RISK FACTORS
Clinical Features
Investigations
Treatment of H. Mole
Follow-up
Role of Prophylactic Chemotherapy in H. Mole
Future Pregnancy
Contraception
NON-OBSTETRIC CAUSES OF BLEEDING IN FIRST TRIMESTER
Bleeding from Cervical Erosion
Cervical Polyp
Carcinoma Cervix
CHAPTER 19:
Hyperemesis Gravidarum
NAUSEA AND VOMITING IN PREGNANCY
Causes of Nausea and Vomiting in Pregnancy
Vomiting in Early Pregnancy
Vomiting in Late Pregnancy
Effects on the Foetus
Effects on the Mother
Mechanism of Vomiting (Flow chart 19.1)
Laboratory Investigations (Table 19.1)
Management (Flow chart 19.2)
CHAPTER 20:
Recurrent or Habitual Miscarriage
AETIOLOGY
Genetic Abnormalities
Reasons
Endocrine Factors
Infections and Chronic Diseases
Anatomic Abnormalities of the Uterus
Immunological Causes
Autoimmune Factors (Immunity Against Self)
Antinuclear Antibody (ANA)
Alloimmune (Immunity Against Another Person-Foetus and Father) Factors
Therapy
Defective Placentation
MANAGEMENT
History
Investigations
Examination
Treatment of Specific Aetiology
Luteal Phase Defect
Polycystic Ovarian Disease (PCOD) Tests
Hyperandrogenism
Abnormal Placentation
Uterine Anomalies
Immunological Causes
Cervical Incompetence
Indications of USG in Recurrent Pregnancy Loss
Management of Recurrent Pregnancy Loss
SECTION 6: COMPLICATION IN PREGNANCY
CHAPTER 21:
Premature Rupture of Membranes (PROM)
DEFINITION
TERM
AETIOLOGY
DIAGNOSIS
Clinical Features
Symptoms
History
Differential Diagnosis
Examination
Management
Investigations on Admission
Indications for Immediate Delivery
DETERMINE THE GESTATIONAL AGE USING FOLLOWING PARAMETERS
Clinical
Ultrasound
MANAGEMENT PLAN ACCORDING TO GESTATIONAL AGE (FLOW CHART 21.1)
EXPECTANT MANAGEMENT OF PATIENTS IN THE WARD
Monitoring
Maternal Parameters
Foetal Parameters
Treatment
Indication for Termination of Expectant Management
Management During Labour
SPECIAL CASES
CHAPTER 22:
Preterm Labour
DEFINITION
AETIOLOGY
Maternal factors causing preterm labour
Trauma may cause premature labour
Genetic
Foetal factors causing preterm labour
Iatrogenic/Elective Preterm Labour
PATHOGENESIS
PREVENTION OF PRETERM BIRTH
Primary Prevention
Secondary Prevention
DIAGNOSIS
MANAGEMENT OF PRETERM LABOUR
Physical Examination
Investigations
Tocolytic Therapy
Contraindications for Tocolysis
CARE OF PREMATURE NEWBORN
Basic Care
Danger Signs
Preterm Infants are at a Greater Risk for
Long-term Morbidity
CHAPTER 23:
Post-term Pregnancy
INTRODUCTION
Post-maturity Syndrome
AETIOLOGY
Causes of Post-term Pregnancy
DIAGNOSIS
On Examination
COMPLICATION
During Pregnancy
During Labour
Maternal
Foetal
Following Delivery
MANAGEMENT (FLOW CHART 23.1)
CHAPTER 24:
Antepartum Haemorrhage
DEFINITION
INCIDENCE
CAUSES
PLACENTA PRAEVIA (UNAVOIDABLE HAEMORRHAGE)
Definition
Incidence
Types/Degrees of Placenta Praevia
Grade/Type I (Lateral/low lying)
Grade/Type II (Marginal)
Grade/Type III (Partial/Incomplete Central)
Grade/Type IV (Total/complete/central)
Causes
Generally Accepted Theories
Predisposing Factors
Cause of Haemorrhage
Clinical Features
Symptoms
Signs
Diagnosis
I. Clinical
II. Investigations
Investigation for Management
Complications (Box 24.1)
Management
Prevention of Maternal Morbidity and Mortality by Early Detection is Very Important
Plan of Management
Route of Delivery is Decided based on Type of Placenta Praevia
Difficulties Encountered During Caesarean Section in Placenta Praevia
Indeterminate Bleeding
ABRUPTIO PLACENTAE (ACCIDENTAL HAEMORRHAGE)
Definition
Incidence
Revealed Haemorrhage
Concealed Haemorrhage
Mixed Haemorrhage
Aetiology/Risk Factors
Pathology
Coagulation Failure (Coagulopathy) Defibrination and Excess Fibrinolysis
Clinical Features of Accidental Haemorrhage
Symptoms
Signs
Investigations
Management
Principle of Management
General Measures
Specific Measures
COUVELAIRE UTERUS (UTEROPLACENTAL APOPLEXY) (FIG. 24.7)
Complications
Maternal
Foetal
Difference Between Placenta Praevia and Abruptio Placentae (Box 24.4)
CHAPTER 25:
Multifoetal Gestation
INTRODUCTION
DEFINITION
INCIDENCE
AETIOLOGY
TYPES OF TWINS
Dizygotic or Binovular Twins
Monozygotic or Uniovular Twins or Identical Twins
DETERMINATION OF ZYGOSITY
PROGNOSIS
Perinatal Mortality
EFFECTS OF TWIN PREGNANCY ON MOTHER
EFFECTS OF MULTIPLE PREGNANCY ON FOETUS
Vanishing Twin
Prematurity
Growth Restriction
Discordant Twins (Fig. 25.6)
Intrauterine Foetal Demise of One Twin (Acute Intertwin Transfusion)
Twin to Twin Transfusion Syndrome (TTTS) (Chronic Intertwin Transfusion)
Superfetation and Superfecundation
Cord Entanglement
Malpresentation
MATERNAL COMPLICATIONS
FOETAL COMPLICATIONS
Cerebral Pathology
Congenital Anomalies
MANAGEMENT DURING ANTENATAL PERIOD
Antenatal Follow-up
Multifoetal Reduction
Early Detection and Possible Prevention of Pre-term Labour
Cervical Score
Stillbirth
Elective Caesarean in Twin Pregnancy
Contentious Indications for Caesarean in Twins
Management of Twins during Labour (Flow chart 25.1)
Intrapartum management (Flow chart 25.1)
Interlocking (Fig. 25.11)
Stimulation of Lactation
Care of the Newborn
CHAPTER 26:
Isoimmunisation and Other Autoimmune Disorders in Pregnancy
INTRODUCTION
Role of Rhesus Blood Group in Pregnancy
ISOIMMUNISATION
Incidence
Pathogenesis
Manifestation of Haemolytic Disease
Maternal
Foetal Manifestations
Theories
Diagnosis
Management (Flow chart 26.2)
Management of Unsensitised Rh Negative Pregnant Women
PREVENTION
Prevention
Active Immunisation
Mode of Action
Dose
Amount of Foetomaternal Blood
Collection of Cord Blood in all Rh Negative Patients
INTRAUTERINE TRANSFUSION
MINOR BLOOD GROUPS
NEONATAL JAUNDICE
Common Causes
Clinical Assessment
Investigation
Complications
Treatment
Prevention
AUTOIMMUNE DISORDERS IN PREGNANCY
Introduction
MECHANISM OF IMMUNOLOGIC TISSUE INJURY IN AUTOIMMUNE DISORDERS (FLOW CHART 26.4)
IMMUNOLOGICAL ASPECTS IN PREGNANCY
AUTOIMMUNE DISORDERS OF IMPORTANCE IN PREGNANCY
ANTIPHOSPHOLIPID ANTIBODY SYNDROME
CLINICAL CRITERIA
LABORATORY CRITERIA
INCIDENCE OF APS (ANTIPHOSPHOLIPID SYNDROME)
PATHOPHYSIOLOGY OF ANTIPHOSPHOLIPID SYNDROME
Clinical Features of APS
Diagnosis of APS
Lupus Anticoagulant
Anticardiolipin Antibodies
Indications for Testing Antiphospholipid Antibodies
Management
Regime of Aspirin and Heparin
Systemic Lupus Erythematosus (SLE)
Definition
Genetic
Sex Hormonal
Environmental
INVESTIGATIONS
Diagnosis of SLE
Prognosis of SLE
Follow up Tests
Foetal Evaluation
EFFECTS OF SLE ON PREGNANCY
Maternal Outcome
Perinatal Outcome
Effect of Pregnancy on SLE
Lupus Flares
Chorea
Management of SLE
AUTOIMMUNE THYROID DISORDER
RHEUMATOID ARTHRITIS
Clinical Features
Management
Effect of Pregnancy on Disease
Effect on Pregnancy
SCLERODERMA
Clinical Features
Effect on Pregnancy
VASCULITIS SYNDROMES
DERMATOMYOSITIS AND POLYMYOSITIS
CHAPTER 27:
Intrauterine Foetal Death
INTRODUCTION
AETIOLOGY
Foetal Causes (25–40%)
Placental (25–35%)
Maternal (5–10%)
Unexplained (25–35%)
PATHOLOGY
CLINICAL FEATURES
COMPLICATIONS
MANAGEMENT (FLOW CHART 27.1)
Investigations
Ultrasonography
Straight X-ray Abdomen
Routine and Special Investigations
TREATMENT
Expectant Management
Induction of Labour
Complications
PREVENTION
SECTION 7: MEDICAL DISORDERS AFFECTING PREGNANCY
CHAPTER 28:
Pregnancy with Heart Disease
CARDIOVASCULAR SYSTEM (CVS) CHANGES DURING PREGNANCY
CHANGES DURING LABOUR, DELIVERY AND POSTPARTUM PERIOD
MANAGEMENT
Management of Heart Disease in Pregnancy
Medical Management of Cardiac Disease in Pregnancy (Based on Aetiology)
Physical Examination
Special Investigation
Antenatal Care
RHEUMATIC HEART DISEASE (RHD)
Mitral Stenosis (MS)
Management in Labour (Box 28.1)
Induction of Labour
Management of Cardiac Failure
Puerperium
Contraception
MATERNAL MORTALITY IN HEART DISEASE
FOETAL OUTCOME
COMPLEX CONGENITAL HEART DISEASE (CCHD) IN PREGNANCY
PULMONARY HYPERTENSION
CARDIOMYOPATHY
ISCHAEMIC HEART DISEASE
SURGERIES FOR HEART DISEASE DURING PREGNANCY
Indications for Surgery
Surgical Techniques for Treatment of Rheumatic Mitral Stenosis
Valvotomy
Valve Replacement
Prosthetic Cardiac Valves
Durability and Thrombogenicity
SURGERY IN CONGENITAL HEART DISEASE
INDICATIONS FOR MEDICAL TERMINATION OF PREGNANCY
ANAESTHESIA
INDICATIONS OF ANTICOAGULATION IN PREGNANCY
DRUGS AVAILABLE FOR ANTICOAGULATION
Heparin
Side Effects
Oral Anticoagulants (e.g. Warfarin)
Low Molecular Weight Heparin
Antiplatelet Drugs
Indications for Prophylactic Digitalisation
CONTRACEPTION IN PATIENTS WITH HEART DISEASE AND PREGNANCY
WHO Categories for Temporary Methods
CHAPTER 29:
Alteration of Haemostatic System and Coagulation Disorders in Pregnancy
FIBRINOLYTIC SYSTEM (FLOW CHART 29.3)
Plasminogen Activators
Fibrinolytic Inhibitors
COAGULATION INHIBITORS
HAEMOSTATIC CHANGES IN PREGNANCY
Common Tests for Integrity of Haemostatic Mechanism (Box 29.1)
DISSEMINATED INTRAVASCULAR COAGULATION (DIC)
Pathogenesis
Aetiology
Commonest Test for Haemostatic Integrity
Clinical Features
Management
VENOUS THROMBOEMBOLISM (VTE)
Pathophysiology
Natural History of Venous Thrombosis
Treatment
Diagnosis
Deep Vein Thrombosis (DVT)
Clinical Features
Phlegmasia Cerulea Dolens
Thromboprophylaxis
Agents for Thromboprophylaxis
CHAPTER 30:
Hypertension in Pregnancy
INCIDENCE
DEFINITION
MEASUREMENT OF BLOOD PRESSURE
CLASSIFICATION OF HYPERTENSION IN PREGNANCY
Gestational Hypertension
Pre-eclampsia
Eclampsia
Pre-eclampsia or Eclampsia Superimposed on Chronic Hypertension
Chronic Hypertension
AETIOLOGY
Risk Factors
Pathophysiology of Hypertension Induced by Pregnancy
Immunological Theory
PATHOLOGY
Placenta
CHANGES IN MATERNAL SYSTEMS
The Kidneys
The Liver
The Brain
Changes in the Eye
Cardiovascular System
Changes in Blood Coagulation
Respiratory System Changes
GESTATIONAL HYPERTENSION
Management
Mild Gestational Hypertension
Severe Gestational Hypertension
PRE-ECLAMPSIA
Mild Pre-eclampsia
Severe Pre-eclampsia is Characterised by
Biochemical Abnormalities in Pre-eclampsia
Renal Function
Hepatic Function
Haematological Changes
Criteria for Diagnosis of Pre-eclampsia
Prediction of Pre-eclampsia
Complications of Pre-eclampsia
Early Complications
Late Complications
HELLP Syndrome (of Weinstein)
Differential Diagnosis of HELLP Syndrome
Criteria for Diagnosis for HELLP Syndrome
Management of Pre-eclampsia
Objectives in Management of Pre-eclampsia are
Mild Pre-eclampsia
Monitoring of Maternal Condition
Monitoring of Foetal Condition
Severe Pre-eclampsia
Laboratory Evaluation for Pre-eclampsia
Definitive Management of Severe Pre-eclampsia is Termination of Pregnancy
Pregnancy Before 28 Weeks of Gestation
Pregnancy Between 28 and 34 Weeks of Gestation
Expectant Management of Severe Pre-eclampsia-Less than 36 Weeks
Pregnancy More than or Equal to 36 Weeks of Gestation
Prevention of Pre-eclampsia
Role of Corticosteroids
Prophylactic Anticonvulsant Treatment in Severe Pre-eclampsia
Antihypertensive Treatment (Table 30.1)
Nitric Oxide Donor
Intravenous Fluid
Management of Labour in a Patient with Pre-eclampsia
Criteria of Delivering Patients with Severe Pre-eclampsia
Anaesthesia in Severe Pre-eclampsia
Maternal and Perinatal Outcome in Pre-eclampsia
Postnatal Assessment
ECLAMPSIA
Types of Eclampsia
Atypical Eclampsia
Causes of Convulsions
Clinical Presentations
Laboratory Findings
Management
Control of Convulsions (Flow chart 30.1)
Magnesium Sulphate (MgSO4)
Phenytoin
Diazepam
Antihypertensive Therapy
Prognosis
CHRONIC HYPERTENSION WITH PREGNANCY
Diagnosis
Classification of Chronic Hypertension
Primary Hypertension or Essential Hypertension
Secondary Hypertension
Evaluation of Patient
Laboratory Investigation
Management
Superimposed Pre-eclampsia on Chronic Hypertension
Management of Pregnant Women with Secondary Causes of Hypertension
CHAPTER 31:
Renal Disorders Complicating Pregnancy
MANAGEMENT
CHAPTER 32:
Diabetes and Other Endocrine Disorders in Pregnancy
DIABETES MELLITUS
Insulin Resistance
Accelerated Lipolysis
Changes in Gluconeogenesis
Classification of Diabetes Mellitus (Tables 32.1 and 32.2)
Maternal Complications of Gestational Diabetes Mellitus
Foetal and Neonatal Complications
Congenital Anomalies
Diagnosis
Management of Diabetes in Pregnancy
Aims of Management
Pre-pregnancy Counselling
Examination
Investigations
Care During Pregnancy
Indications of Insulin Therapy
Insulin Therapy
Timing of Delivery
Route of Delivery
Management of Vaginal Delivery
Indications of Elective Caesarean Section
Postpartum Care
Postpartum Contraceptive Advice
OTHER ENDOCRINE DISORDERS AND PREGNANCY
Pituitary Diseases
Acromegaly
Diabetes Insipidus (DI)
Diseases of Adrenal Glands
Cushing Syndrome
Congenital Adrenal Hyperplasia
Phaeochromocytoma
Diseases of Parathyroid Gland
CHAPTER 33:
Infants of Diabetic Mothers (IDMs)
COMPLICATIONS IN IDMs
Macrosomia
Hypoglycaemia
Prevention
Monitoring
Management
Asymptomatic Hypoglycaemia
Symptomatic Hypoglycaemia
Hypocalcaemia
Management
Hyperbilirubinaemia
Polycythaemia
Respiratory Distress
Congenital Anomalies
Poor Feeding
Myocardial Dysfunction
Renal Vein Thrombosis
Long-Term Risks
CHAPTER 34:
Pregnancy Associated with Gynaecological and Surgical Disorders
OVARIAN TUMOURS
Management
UTERINE LEIOMYOMA ASSOCIATED WITH PREGNANCY
Effect of Myoma on Pregnancy
Effect of Pregnancy on Myoma
CARCINOMA
RETROVERTED GRAVID UTERUS
PREGNANCY WITH PROLAPSE OF UTERUS
SURGICAL CONDITIONS DURING PREGNANCY
ACUTE APPENDICITIS
DIFFERENTIAL DIAGNOSIS
ACUTE CHOLECYSTITIS AND CHOLELITHIASIS
ACUTE PANCREATITIS
PEPTIC ULCER DISEASE
ACUTE INTESTINAL OBSTRUCTION
HAEMORRHOIDS
CHAPTER 35:
Thyroid Disease and Pregnancy
INTRODUCTION
Functions of Thyroid Gland in Normal Pregnancy
Presentation of Thyroid Diseases in Pregnancy (Fig. 35.1)
Hyperemesis Gravidarum
Autoimmune Thyroid Disease
Primary Hypothyroidism
Thyrotoxicosis
Thyroid Crisis (Thyroid Storm)
Nodular Thyroid Disease
Endemic Goitre (Fig. 35.1)
Postpartum Thyroid (PPT) Disorders
Postpartum Thyroiditis
Postpartum Graves' Disease
Congenital Hypothyroidism
Neonatal Hyperthyroidism
CHAPTER 36:
Respiratory Disorders in Pregnancy
DYSPNOEA OF PREGNANCY
PULMONARY PATHOLOGY AND PREGNANCY
Asthma
Effect on the Foetus
Treatment
Beta 2 Agonists
Anti-inflammatory Drugs
Bronchodilators
Corticosteroid
Management of Asthma During Labour
Bronchiectasis
Consolidation
Adult Respiratory Distress Syndrome (ARDS) in Pregnancy
Amniotic Fluid Embolism
Prevention
Diagnosis
Laboratory Findings
Differential Diagnosis of Amniotic Fluid Embolism
Pleural effusion
Treatment
Aspiration of Gastric Content (Mendelson's Syndrome)
Treatment
TRAUMA
CHAPTER 37:
Tuberculosis in Pregnancy
INTRODUCTION
EFFECT OF TUBERCULOSIS ON PREGNANCY
EFFECT OF PREGNANCY ON TUBERCULOSIS
PATHOGENESIS
CLINICAL MANIFESTATIONS
INVESTIGATIONS
TREATMENT (TABLES 37.1 AND 37.2)
MANAGEMENT
Management During Labour and Postnatal Period
Management of Neonate
CONGENITAL TUBERCULOSIS
HIV, TUBERCULOSIS AND PREGNANCY
CONCLUSION
CHAPTER 38:
Mother to Child Transmission of HIV
HIV INFECTION RATE (TABLES 38.1 TO 38.5)
RISK FACTORS (BOX 38.1)
Risk Factors in Females
Biological Factors
Previous RTI/STI
ISSUES CONCERNING PREGNANCY
Determinants of Vertical Transmission (Box 38.2)
Viral Load
Concurrent STI
Unprotected Sexual Intercourse
Maternal CD-4 and Lymphocyte Count
Mother's Neutralizing Antibody Monoclonal HIV-3
Nutritional Status
Rupture of Membranes
Type of Virus
Placental Barrier
Presence and Amount of Virus in the Genital Tract
Smoking and Illicit Drug Use
Foetal Factors
TIMING OF VERTICAL TRANSMISSION
MANAGEMENT OF HIV POSITIVE PREGNANT WOMEN
INTERVENTIONS AIMED AT DECREASING THE RISK OF MOTHER TO CHILD TRANSMISSION (MTCT) OF HIV INFECTION (BOX 38.3)
Primary Prevention
Secondary Prevention
Counselling
General Measures
Obstetric Measures
Immunological
Antiretroviral Drugs
NEVIRAPINE-(HIV/NET 0/2)
Precautions Taken
Precautions Taken During MTP or Delivery of HIV-Positive Women (Figs. 38.4A and B)
Barrier
Disinfectant Solution
Precaution During Operation
During Delivery
EFFECT OF PREGNANCY ON HIV DISEASE
EFFECT OF HIV ON PREGNANCY
HIV-EXPOSED NEWBORN
CONTRACEPTION AND HIV
Intrauterine Contraceptive Devices
Barrier and Spermicide
Oral Contraception
ETHICS AND HIV DISEASE IN WOMEN
CHAPTER 39:
Liver Diseases in Pregnancy
TYPES OF THE LIVER DISEASES
DISEASES SPECIFICALLY DUE TO PREGNANCY
Intrahepatic Cholestasis of Pregnancy
Clinical Features
Incidence
Aetiology
Investigations
Treatment
Acute Fatty Liver of Pregnancy (AFLP)
Aetiology
Clinical Features
Investigations
Differential Diagnosis
Course and Prognosis
Treatment
Liver Disease in Pre-eclampsia and Eclampsia
Severe Form of HELLP
Differential Diagnosis
In Hyperemesis Gravidarum
DISEASES COINCIDENTAL TO PREGNANCY
Acute Viral Hepatitis
Hepatitis A Virus
Hepatitis B Virus
Treatment is Supportive
Hepatitis C
Hepatitis D
Hepatitis E
Hepatitis G
The Clinical Picture of Hepatitis
Diagnosis
Treatment of Viral Hepatitis
Fulminant Hepatitis
Toxic Hepatitis
CHRONIC LIVER DISEASE THAT ANTEDATES PREGNANCY
DISEASES OF THE GALLBLADDER
CHAPTER 40:
Malaria in Pregnancy
EFFECT OF PREGNANCY ON MALARIAL COURSE
EFFECTS OF MALARIA ON PREGNANCY
CONGENITAL MALARIA
CLINICAL PRESENTATION
Diagnosis of Maternal Malaria (Figs 40.1 and 40.2)
Chemoprophylaxis
CHAPTER 41:
Psychiatric Disorders in Pregnancy and Puerperium
PSYCHIATRIC ASPECTS OF OBSTETRICS
MENTAL ILLNESS IN PUERPERIUM
Introduction
Classification of Mental Disorders in the Puerperium
Puerperal Mood Disorders (Table 41.1)
Maternity Blues (Postpartum Blues)
Clinical Features
Treatment
Postpartum Depression
Clinical Features
Treatment
Postpartum Psychosis
Aetiology
Clinical Features
Treatment
Prevention
CHAPTER 42:
Skin Disorders in Pregnancy
PIGMENTATION
Blood Vessels
VARICOSITIES
Treatment
Drug
STRIAE GRAVIDARUM (FIG. 42.4)
SKIN TAGS OR MOLLUSCUM FIBROSUM GRAVIDARUM
GINGIVITIS
PRURITIC CONDITIONS
Treatment
Polymorphic Eruption in Pregnancy
PEMPHIGOID (HERPES GESTATIONALIS)
OTHER SKIN DISEASES
Acne
Prurigo of pregnancy
Psoriasis (Fig. 42.5)
Atopic eczema
Erythema Multiforme
Lupus Erythematosus
Warts in Pregnancy
CHAPTER 43:
Epilepsy in Pregnancy
DEFINITION
Epilepsy
Effect of Pregnancy on Epilepsy
Effect of Epilepsy on Pregnancy
Effect of Anticonvulsant Medications on the Foetus
Pathophysiology of Effect of Drugs on the Foetus
Effect of Epilepsy on the Foetus or Neonate
Preconceptional counselling
Care of the Patient during Pregnancy
Differential Diagnosis
Labour and Delivery
New Onset of Seizures in Pregnancy and the Puerperium
Investigations
Postpartum Period and Breastfeeding
Contraception
Status Epilepticus
Management
CHAPTER 44:
Anaemia in Obstetrics
DEFINITION OF ANAEMIA
WHO Classification of Anaemia
Prevalence of Anaemia
Classification of Anaemias
By Aetiology of Anaemia in Pregnancy
Based on Red Cell Indices
IRON DEFICIENCY ANAEMIA
Iron Requirements in Pregnancy (Table 44.1)
Reasons for High Prevalence of Iron Deficiency Anaemia in Pregnancy
Factors Affecting Iron Absorption
Clinical Features of Iron Deficiency Anaemia
Investigations
Laboratory Iron Studies
Bone Marrow Stores Evaluation (Table 44.2)
Consequences of Iron Deficiency Anaemia
Maternal Effects
Foetal Effects
Management of Iron Deficiency Anaemia
Prevention Strategies
Newer Strategies
Differential Diagnosis
Treatment Based on Gestational Age
Duration of Therapy
Side Effects of Oral Therapy
Parenteral Therapy
Dosage (Table 44.5)
Place of Blood Transfusion
Partial Exchange Transfusion (Figs 44.3A to C)
Management of Labour in Patients with Anaemia
Puerperium
MEGALOBLASTIC ANAEMIA
Folic Acid Deficiency
Aetiology
Clinical Features
Effect on Pregnancy
Effect on Foetus
Investigations
Prophylaxis
Treatment
Cyanocobalamin Deficiency
Aetiology
Clinical Features
Investigations
Treatment
DIMORPHIC ANAEMIA
ANAEMIA FROM ACUTE BLOOD LOSS
HAEMOLYTIC ANAEMIAS
Acquired Haemolytic Anaemia
Pregnancy Induced Haemolytic Anaemia
Paroxysmal Nocturnal Haemoglobinuria
Other Acquired Anaemias
Haemoglobinopathies
Sickle Cell Anaemia
Sickle Cell Trait
Sickle Cell Disease
Effect on Pregnancy and Foetus
Effect of Disease
Management
Preconceptional Counselling
Pregnancy
Labour
Contraception
Experimental Therapy
THALASSAEMIA SYNDROMES
Alpha-thalassaemia Syndromes
Hb Barts (Gamma 4)
Alpha Thalassaemia Minor
Beta Thalassaemia
Beta Thalassaemia Minor
Thalassaemia Major
NESTROFT (NAKED EYE SINGLE TUBE RED CELL OSMOTIC FRAGILITY TEST)
PREVENTION
SECTION 8: SPECIAL CASES IN PREGNANCY
CHAPTER 45:
Care of Pregnant Patient with Previous Caesarean Section
CHAPTER 46:
High-Risk Pregnancies
DEFINITION
CHAPTER 47:
Teenage Pregnancy and Its Complications
INTRODUCTION
INCIDENCE
Social Risk Factors for Teenage Pregnancy Include
Diagnosis
Medical Risks to Teenage Mothers
Risks to Infants
Long-term Effects of the Condition
COUNSELLING
COUNSELLING AND PRENATAL EDUCATION
CHAPTER 48:
Elderly Primigravidae
COMPLICATIONS
Maternal
Intrapartum Complications
Postpartum Complications
Perinatal Complications
Management
CHAPTER 49:
Grand Multiparity
DEFINITION
MAGNITUDE OF PROBLEM
COMPLICATIONS
COMPLICATIONS DURING LABOUR
Puerperium
MANAGEMENT
Labour
CHAPTER 50:
Trauma in Pregnancy
ROAD SIDE ACCIDENTS
SEAT BELT
MANAGEMENT
PENETRATING ABDOMINAL TRAUMA
CHEST AND HEAD INJURIES
BURNS
ELECTRIC BURNS
SECTION 9: FOETAL DISORDERS
CHAPTER 51:
Disproportional Foetal Growth
INTRODUCTION
Intrauterine Growth Restriction- Small for Gestation
Asymmetric IUGR
Aetiology
Foetal Causes
Maternal Causes
Placental Causes
Diagnosis
Doppler Study
Management
Foetal Surveillance
Care During Delivery
Early Neonatal Manifestations
Long-term Sequences
LARGE FOR GESTATIONAL AGE (LGA) OR MACROSOMIA
Definition
Mechanism
Causes
Maternal
Foetal
Complications
Maternal Complications
Foetal Complications
Newborn Complications
Long-term Complications
Prevention
Primary Prevention
Secondary Prevention
Diagnosis
History
Examination
Investigations
Management
Shoulder Dystocia
Methods for Conduction of Delivery in Cases of Shoulder Dystocia
CHAPTER 52:
Infection During Pregnancy
MATERNAL INFECTION
Mechanism of Action
Role of Maternal Infection in Intraventricular Haemorrhage (IVH) of the Newborn
Cerebral Palsy (CP) and Maternal Infection
Bronchopulmonary Dysplasia (BPD) and Intra-uterine Infections
TORCHS Infection
Toxoplasmosis
Prevention of Toxoplasmosis
Chlamydial Infection
Chickenpox
Gonorrhoea
Rubella
Congenital Rubella Syndrome
Cytomegalovirus (CMV)
Herpes Simplex Virus
Syphilis
Kassowitz Law
Congenital Syphilis
Rabies in Pregnancy
CHAPTER 53:
Clinical Pharmacology in Obstetrics
HAEMATINICS IN PREGNANCY
Iron
Folic Acid
Calcium
UTERINE STIMULANTS OR OXYTOCICS
Oxytocin
Physiological Roles of Oxytocin
Uses
Adverse Effects
Ergot Derivatives: Ergonovine and Methylergonovine
Contraindications
Side Effects
Prostaglandins
Abortion
Induction/Augmentation of Labour
Cervical Ripening
Postpartum Haemorrhage
Dinoprostone
Relative Contraindications
Absolute Contraindications
Side Effects
Misoprostol
Advantages
UTERINE RELAXANTS (TOCOLYTICS)
HYPEREMESIS GRAVIDARUM
Antiemetics
Promethazine
Prochlorperazine
Ondansetron
Droperidol
Metoclopramide
Pyridoxine (Vitamin B6)
Thiamine (Vitamin B1)
ASTHMA IN PREGNANCY
Medications
Doses
HYPERPROLACTINAEMIA IN PREGNANCY
Dose
ANTIEPILEPTICS IN PREGNANCY
Valproic Acid
Carbamazepine
Phenytoin
Phenobarbital
ANTICOAGULANTS IN PREGNANCY
Warfarin
Heparin
ANTIHYPERTENSIVES IN PREGNANCY
Alphamethyldopa
Beta-blockers
Vasodilators
Hydralazine
Calcium Channel Blockers
ANTIHYPERTENSIVES
Hydralazine
Labetalol
ALCOHOL
Diuretics
Angiotensin Converting Enzyme Inhibitor
DRUGS TO TERMINATE SEIZURES
Magnesium Sulphate
Phenytoin
Lytic Cocktail Therapy
Diazepam (Valium)
VACCINES
ANTITHYROID DRUGS
Drugs for Toxoplasmosis
ANTIANXIETY DRUGS
ANTIDEPRESSIONS
LITHIUM
ANTIBIOTICS
ANTIPARASITIC
ANTIVIRAL
ANTICANCER DRUGS
X-RAY THERAPY
ANTIHISTAMINICS
HORMONES
Diethylstilbestrol (DES)
ISOTRETINOIN
TERATOGEN
FDA CATEGORIES OF DRUGS AS TERATOGEN
THALIDOMIDE
GENERAL ASPECTS OF PHARMACOLOGY IN PREGNANCY
CHAPTER 54:
Foetal Anomalies in First Trimester
CONGENITAL ANOMALIES
High-risk Factors
Pregnant Woman of Advanced Age
Role of Ultrasound in Anatomical Abnormalities in First Trimester (Flow Chart 54.1)
Ultrasound Markers of Chromosomal Abnormalities
Nuchal Translucency (NT)
Biochemical Markers
Combination Screening in First Trimester
Invasive Techniques in First Trimester
Congenital Nervous System Disease Diagnosis
Basic Types of Neural Defect
Aetiology
USG Findings
Associated Anomalies
Prognosis
Management
Hydrocephalus
Common Types of Hydrocephalus
Investigation
Associated Anomalies
Management of Hydrocephalus
Congenital Heart Disease
Omphalocele
Incidence
Aetiology
Associated Anomalies
Diagnosis
Prognosis
Management
Gastroschisis
Associated Anomalies
Diagnosis
Prognosis
Management
Diaphragmatic Hernia
Incidence
Associated Anomalies
Diagnosis
Management
Sacrococcygeal Teratoma (Fig. 54.2)
Diagnoses
Prognosis and Management
SECTION 10: NORMAL LABOUR AND DELIVERY
CHAPTER 55:
The Passageway and the Passenger
PARTURITION (OR LABOUR)
THE PASSAGEWAY (MATERNAL PELVIS)
Anatomy (Figs 55.1 and 55.2)
Pelvic Inlet (or brim) (Fig. 55.1)
False Pelvis (Figs 55.2 and 55.3)
True Pelvis
Inlet
Plane
Obstetrical Significance
Axis of Inlet
DIAMETERS OF PELVIC INLET (FIGS 55.5 AND 55.6)
CAVITY
Definition
Plane of Least Pelvic Dimensions (or Narrow Pelvic Plane)
Plane of Cavity
Shape of Cavity
Axis of Cavity
Diameters
Antero-posterior Diameter (12 cm)
Transverse Diameter (12 cm)
MID PELVIS
Mid Pelvic Plane
Diameter of Mid Pelvis
Bi-spinous or Transverse Diameter (10.5 cm)
Obstetric Significance of Cavity
Importance of Ischial Spines (Plane of least pelvic dimension)
OUTLET
Obstetrical Outlet
Shape
Plane
Axis
Diameters
Anatomical Outlet
Shape
Plane
Axis
Diameters
PELVIC AXIS
Anatomical
THE PASSENGER (OR THE FOETUS)
Foetal Head (or skull or cranium) (Figs 55.12 and 55.13)
Fontanelles
Presenting Parts of Foetal Skull
Diameters/Circumferences of Skull (Fig. 55.15)
Engagement of Foetal Head
Changes in Foetal Skull During Labour
Moulding
Grading
Caput Succedaneum (Fig. 55.19)
Obstetric Significance
CHAPTER 56:
Mechanism of Labour
DEFINITION OF LABOUR
LIE
PRESENTATION
POSITION
THEORIES OF ONSET OF LABOUR
Stretching of Uterus
Foetal Hypothalamic Pituitary Adrenal Axis
Uterotonic Theory of the Initiation of Labour
MECHANISM OF LABOUR
Cardinal Movements (Fig. 56.3)
Engagement
Descent
Flexion
Internal Rotation
Extension
Restitution
External Rotation
Mechanism of Labour in ROA
CHAPTER 57:
Stages of Labour
DEFINITION OF NORMAL DELIVERY
LABOUR
First Stage
Second Stage
Third Stage
Fourth Stage
PHYSIOLOGY OF LABOUR
Physiology of First Stage of Labour
Softening of Cervix
Effacement of Cervix (Figs 57.1A to F)
Dilatation of the Cervix or External Os of the Cervix
Characteristics of Uterine Contractions
Formation of Upper and Lower Segment
Physiology of Second Stage of Labour
Physiology of Third Stage of Labour
Placental Separation
Placental Expulsion
SUMMARY OF PHYSIOLOGICAL CHANGES IN LABOUR
CHAPTER 58:
Management of Normal Labour
INTRODUCTION
PREMONITORY SIGNS OF LABOUR
Show
Rupture of Membranes
ONSET OF LABOUR
True Versus False Labour
Admission Criteria
Confirm Active Labour Before Admitting
Initial Assessment at the Time of Admission
Comprehensive History
Investigations
Examination
Consent
At the time of admission to the labour room
Estimation of Station of Presenting Part (Figs 58.3A and B)
PARTOGRAPH (FIGS 58.4 TO 58.6)
Partograph and Clinical Decision Making
WHO Partograph
Advantages of Partograph
Limitation of Partograph
CHAPTER 59:
Conduct of Normal Labour
FIRST STAGE OF LABOUR
Latent Phase of the First Stage
Active Phase of the First Stage
Principles of Management
Maternal Wellbeing
SECOND STAGE OF LABOUR
Principles of Management
Delivery of Head
Suction Should be Done After Delivery of the Head
Baby Should be Kept Below the Level of the Perineum
THIRD STAGE OF LABOUR
Watchful Expectancy
Active Management
Modified Brandt's Andrew Technique (Controlled cord traction)
Episiotomy/Perineal tear repair
FOURTH STAGE OF LABOUR
SUMMARY OF MANAGEMENT OF NORMAL LABOUR (TABLE 59.1)
Programmed Labour
Ensure Pain Relief
CHAPTER 60:
Intrapartum Foetal Surveillance
PHYSIOLOGY OF OXYGEN DELIVERY TO THE FOETUS
Utero-placental Perfusion
Intervillous Space Perfusion
Umbilical Circulation
FOETAL RESPONSE TO REDUCED OXYGEN DELIVERY
Foetal Chemoreceptors
Foetal Catecholamines Secretion
Intermittent Auscultation of FHS (IA) (Box 60.1)
Technique of Auscultation
Reassuring Findings
Non-reassuring Findings
Limitations
Colour of the Liquor
Cardiotocographic (CTG) Recording
Admission test (AT)
Duration of Recording
The Advantage Over FHR Auscultation
Assessment of Amniotic Fluid Volume
Umbilical Artery Doppler Velocimetry
Foetal Acoustic Stimulation Test (FAST)
Electronic Foetal Monitoring (EFM)
Indications for Electronic Foetal Monitoring (EFM)
FHR on CTG (Box 60.2)
Bradycardia
Tachycardia
Beat to Beat Variability
Deceleration
Classification of Intrapartum CTG Trace
Normal
Suspicious
Abnormal
Ominous Features
Other specific tracings categorised as abnormal are:
Foetal Scalp Blood Sampling
Disadvantage
Foetal Scalp Stimulation Test
Foetal Pulse Oximetry (Fig. 60.1)
Intrapartum Monitoring with Foetal ECG Waveform Analysis—Foetal ECG ST Segment (Fig. 60.2)
Near Infrared Spectroscopy (NIRS)
FOETAL DISTRESS (FOETAL COMPROMISE, NON REASSURING FOETUS STATUS)
Definition of Nonreassuring FHR
Management of Foetal Distress
Intrauterine Foetal Resuscitation
Prior to LSCS
Meconium
Predisposing Factors
Incidence
Management and Outcome
Amnio Infusion
Management of MAS
Prevention
Role of Amnio Infusion
SECTION 11: NEONATOLOGY
CHAPTER 61:
Newborn Examination and Common Early Neonatal Problems
NEWBORN EXAMINATION
General Examination
Initial Observation
Vitals
Anthropometry
Gestational Assessment
Skull
Eyes
Mouth
Ears
Skin
Extremities
Spine
Systemic Examination
Cardiorespiratory System
Abdomen
Neurologic Examination
Common Early Neonatal Problems
CHAPTER 62:
Neonatal Resuscitation
PHYSIOLOGY OF ASPHYXIA
PREPARATION FOR DELIVERY
Risk Factors
High-Risk Factors
Personnel
Equipment
THE PRINCIPLES OF RESUSCITATION
ROUTINE CARE
Initial Steps of Resuscitation
Positive Pressure Ventilation (PPV)
Indications
Bag and Mask
Procedure of PPV (Fig. 62.2)
Chest Compression
Indications
Technique
Endotracheal Intubation
Indications
Technique of Intubation
Drugs
When to Terminate Resuscitation
Role of Apgar Scoring (Table 62.1)
CONCLUSION
ALGORITHM FOR RESUSCITATION OF THE NEWLY BORN INFANT (FLOW CHART 62.1)
SECTION 12: ABNORMAL LABOUR
CHAPTER 63:
Induction of Labour
DEFINITIONS
Induction of Labour
AUGMENTATION OF LABOUR
INDICATIONS OF INDUCTION OF LABOUR
Maternal Indications
Foetal Indications
For the sake of both mother and foetus
Contraindications
Requirements of Induction
CERVICAL RIPENING
Pre-induction Methods of Cervical Ripening
Pharmacological Agents
Mechanical Methods
METHODS OF INDUCTION OF LABOUR
Physical Methods
Surgical Method
Amniotomy
Pharmacologic Methods
Oxytocin
Prostaglandins
Relaxin
MONITORING OF LABOUR DURING INDUCTION
RISKS AND COMPLICATIONS OF INDUCTION OF LABOUR
FAILURE OF INDUCTION
CHAPTER 64:
Abnormalities of the Passage
CAUSES OF ABNORMALITIES
CONTRACTION OF PELVIS
DEVELOPMENTAL VARIATIONS OF THE PELVIS
Variations in Shape
Gynaecoid Pelvis (Fig. 64.1)
Anthropoid Pelvis (Inlet is Oval) (Fig. 64.2)
Android Pelvis (Fig. 64.3)
Platypelloid Pelvis (Fig. 64.4)
DISEASES AFFECTING THE SKELETAL SYSTEM
Rickets
Osteomalacia
DISEASES AFFECTING THE SPINE
Kyphosis (Fig. 64.5)
Scoliosis
DISEASES AFFECTING THE LOWER LIMB AND HIP JOINT
INJURIES AND DISEASES OF THE PELVIS
VARIATIONS IN SIZE
Inlet Contractions
Mid-pelvis Contraction
Pelvic Outlet Contraction
MANAGEMENT OF CONTRACTED PELVIS
Elective Caesarean Section
Trial of Labour
Obstruction of Birth Canal by Soft Tissue Abnormalities
CHAPTER 65:
Abnormalities of the Passenger
MALPOSITION AND MALPRESENTATION
OCCIPITO-POSTERIOR POSITION
Mechanism of Labour (Figs 65.2A to H and 65.3A to G)
Management (Flow chart 65.1)
Manual Rotation
Vacuum Extraction
Forceps
Face presentation
Incidence
Aetiology
Maternal
Foetal
Diagnosis
Inspection
Palpation
On Per Vaginal Examination
Mechanism of Labour
Course of Labour
Mento-anterior (chin is anterior)
Mento-posterior (chin is posterior)
BROW PRESENTATION (FIG. 65.7)
Management
Transverse Lie
Incidence
Position
Aetiology
Diagnosis
Inspection
Palpation
Auscultation
Per Vaginal Examination
Management During Antenatal Period
Mechanism of Labour
Clinical Course of Labour
Management
Late Labour
Unstable Lie
Stabilising Induction of Labour
Compound Presentation (Fig. 65.10)
Incidence
Aetiology
Diagnosis
Management
Diagnosis
Foetal Macrosomia
Foetal Malformation
CHAPTER 66:
Abnormal Labour Dystocia: Dysfunctional Labour
AETIOLOGY
Abnormalities of Power or Uterine Contractions
CLASSIFICATION OF DYSTOCIA (FIG. 66.1)
Prolonged Latent Phase
Causes of Prolonged Latent Phase may be
Consequences of Prolonged Latent Phase are
Management (Flow chart 66.1)
Management consists of two steps
Protraction Disorders
Causes
Treatment
Arrest Disorders
Aetiology
Arrest of Dilatation
Arrest of Descent
Prolonged Deceleration Phase
Prolonged Second Stage
Precipitate Labour Disorders
Causes
Complications
Foetal Complications in Precipitate Labour
Treatment
PREVENTION OF DYSTOCIA
ABNORMALITIES OF THE POWER
DYSTOCIA DYSTROPHY SYNDROME
EFFECTS OF DYSTOCIA
Intrapartum Infection
Obstructed Labour
Causes
Pathology
Prevention
Diagnosis-Clinical features
Intranatal Period
Abdominal Examination Reveals
Vaginal Examination
Maternal Morbidity and Mortality
Perinatal Morbidity and Mortality
Management of Obstructed Labour
Prevention
Curative Treatment
Rupture of Uterus (Fig. 66.9A and B)
Definitions-Rupture of the Uterus may be Complete or Incomplete
Classification and Aetiology
Rupture During Pregnancy
Rupture During Labour
Rupture of a Previous Caesarean Section Scar
Rupture During Labour
Clinical Features
Rupture During Labour
Prognosis
Management
Definitive Treatment
Specific Measures
Postoperative Period
Pelvic Floor Injury
CHAPTER 67:
Cord Prolapse
UMBILICAL CORD PROLAPSE
Aetiology (Figs 67.1 and 67.2)
Diagnosis
Occult Prolapse (Fig. 67.3)
Cord Presentation (Fig. 67.4)
Cord Prolapse (Fig. 67.5)
Prognosis
Prevention
Management (Flow chart 67.1)
Principles of Management
If the Foetus is Alive
Foetus Dead
Management
CHAPTER 68:
Breech Presentation
DEFINITION
ANTERIOR
POSTERIOR
INCIDENCE
TYPES OF BREECH
AETIOLOGY
Maternal Factors
Placenta, Liquor and Cord Factors
Foetal Factors
DIAGNOSIS OF BREECH PRESENTATION (FIGS 68.3A AND B)
MECHANISM OF LABOUR
Delivery of Lower Limbs and Buttocks (Figs 68.4A to F)
Delivery of Shoulder and Arms (Figs 68.5A to C)
Birth of After Coming Head (Figs 68.6A to C)
MECHANISM OF LABOUR IN OTHER POSITIONS
Sacroanterior Position
Sacroposterior Position
Moulding
INVESTIGATIONS
MANAGEMENT DURING PREGNANCY
MANAGEMENT IN LABOUR
Indications for Elective Caesarean Delivery
Indications For Trial of Labour
First Stage of Labour
Second Stage of Labour (Figs 68.7A and B)
DELIVERY OF THE AFTERCOMING HEAD
Bracht's Manoeuvre/Burns Marshall Manoeuvre (Figs 68.13 A and B)
Wigand-Martin Manoeuvre (Fig. 68.14)
Mauriceau-Smellie-Veit Manoeuvre (Fig. 68.15)
Forceps Delivery (Figs 68.16A to D)
OCCIPITO-POSTERIOR POSITION OF HEAD
TOTAL BREECH EXTRACTION
HYPEREXTENSION OF THE FOETAL HEAD (FIGS 68.17 A AND B)
Aetiology
Diagnosis
Dangers Involved During Delivery
PROGNOSIS FOR BREECH PRESENTATION
Maternal Prognosis
Foetal Prognosis
Injury to the Brain and Skull
Prematurity
Congenital Anomalies
Birth Asphyxia
Foetal Injuries
THE TERM BREECH TRIAL
CAESAREAN SECTION FOR BREECH PRESENTATION
PRETERM BREECH DELIVERY
Birth Weight 1500–2500 Grams
Birth Weight Less Than 1500 Grams (Kitchen et al 1985)
Entrapment of Foetal Head (Fig. 68.18)
CONCLUSIONS
SECTION 13: PUERPERIUM
CHAPTER 69:
Puerperium
INTRODUCTION
IMMEDIATE PUERPERIUM
EARLY PUERPERIUM
REMOTE PUERPERIUM
POSTPARTUM CHANGES
Involution of Uterus (Fig. 69.1)
Lochia
Changes in Cervix
Vagina
Fallopian Tubes
Ovarian Functions
Pelvic Changes
Loss of Weight
Cardiovascular System
Haemodynamic Readjustment
Urinary System
Metabolic Changes
Coagulation Mechanism
Respiratory Changes
Hormonal Changes
Human Placental Lactogen (hPL)
Human Chorionic Gonadotrophin (hCG)
Plasma 17β Estradiol
Progesterone
Prolactin
Serum FSH and LH
Resumption of Menses
Oxytocin and Endogenous Opioids
Pituitary Gland
Thyroid Hormones
Total and Free Adrenocorticotropic Hormone (ACTH)
MANAGEMENT
Post Natal Exercises
Initial Post Natal Exercises (Fig. 69.5)
Sitting (Fig. 69.6)
Feeding (Figs 69.7A to C)
Transcutaneous Nerve Stimulation (TNS) (Fig. 69.10B)
Abdominal wall weakness
Pelvic Floor Exercise
Infrared Irradiation
Backache
In low backache
Coccydynia
Carpal Tunnel Syndrome
When to Report Immediately
Ambulation
Sexual Activity
Nutrition
Emotional Support
Family Planning Advice
Examination and Instructions at the Time of Discharge
Postpartum Visit at Six Weeks
CHAPTER 70:
Breastfeeding
INTRODUCTION
ADVANTAGES OF BREASTFEEDING
Benefits to the Baby
Benefits to the Mother
Benefits to the Family and the Society
VARIATIONS IN THE COMPOSITION OF THE BREAST MILK
Colostrum
Mature Milk
Composition of Human Breast and Cow's Milk
BREASTFEEDING PRACTICES TO BE RECOMMENDED
ANATOMY AND PHYSIOLOGY OF BREAST (FIGS 70.1A AND B)
Physiology of Lactation
Prolactin Reflex
Oxytocin Reflex (Fig. 70.3)
Reflexes in the Baby (Fig. 70.4)
BREASTFEEDING TECHNIQUE
Correct Positioning (Fig. 70.5)
Attachment of Baby on Mothers Breast (Fig. 70.6)
PROBLEMS IN BREASTFEEDING
Inverted/Flat Nipples
Sore Nipple
Suppression of Lactation
Breast Engorgement
Breast Abscess
Not Enough Milk
Treatment: Stimulation of Lactation
Breast Milk Expression
Ten steps to successful breastfeeding
Contraindications of Breastfeeding
Absolute Contraindications
Relative Contraindications
Drugs which have Deleterious Effects on Lactation
BREASTFEEDING AND ITS RELATION TO CONTRACEPTION
Lactational Amenorrhoea Method (LAM)
How does it work?
Effectivity
Correct and Consistent Use Means
Advantages of Breastfeeding as Contraceptive Measure
Disadvantages of Breastfeeding as Contraceptive Method
Counselling
CHAPTER 71:
Abnormal Puerperium
INTRODUCTION
INFECTIONS
Puerperal Pyrexia (Fever)
Puerperal Sepsis
Endometritis (Also Called Metritis or Endoparametritis)
Risk Factors Include
Organisms
Investigations
Morbidity and Mortality
Differential Diagnosis of Puerperal Sepsis Include
Prevention
Wound Infection
Wound Dehiscence (Burst Abdomen)
Necrotising Fasciitis
Pelvic Abscess
Septic Pelvic Vein Thrombosis
Urinary Tract Infection
Lactation Mastitis
Breast Abscess
Endocrine Disorders
Sheehan's Syndrome
Psychiatric Disorders
SECTION 14: OPERATIVE PROCEDURES
CHAPTER 72:
Asepsis and Antisepsis in Operation Theatre
NEED FOR ASEPSIS IN OT
Environment
Personnel
Clothing
Droplet Infection
Falling Hair
Sweat and Body Contamination
THE SURGICAL SCRUB (FIGS 72.3)
Wearing of Surgical Gowns (Figs 72.1A to D)
Wearing of Surgical Gloves (Figs 72.2A to H)
CHAPTER 73:
Obstetric Analgesia and Anaesthesia
GENERAL OBJECTIVES
WHY TREAT LABOUR PAIN?
LABOUR PAIN IS UNIQUE
HOW DID LABOUR, ANALGESIA AND ANAESTHESIA START?
ANALGESIA AND ANAESTHESIA
ANATOMY OF PAIN (FIG. 73.1)
The Pattern of Labour Pain (Fig. 73.2)
Labour Analgesia
Non-Pharmacological Means of Providing Pain Relief
Injectable Pharmacological Agents
Local Analgesia
Regional Analgesia
Epidural Analgesia
Disadvantages
Local Anaesthetic Agents (Table 73.1)
ANAESTHESIA FOR CAESAREAN SECTION
HIGH-RISK CASES
Maternal Starvation and Antacid Therapy
Aorto-caval Compression (Supine Hypotension Syndrome) (Figs 73.3A and B)
Intravenous Access
Postoperative Period
CARDIAC ARREST
CHAPTER 74:
Interpreting Arteriar Blood Gas Sample
PARTIAL PRESSURE
pH SCALE
Acidaemia
Alkalaemia
Acidosis
Alkalosis
Buffers
Standard Bicarbonate
Actual Bicarbonate
Base Excess
ARTERIAL BLOOD GAS SAMPLING: CLINICAL CONSIDERATIONS
Interpretation of a Blood Gas Sample
Step 1: Is there an Acidaemia or Alkalaemia?
Step 2: Look at the PaCO2 and HCO3−
Step 3: Compare with the Expected Changes
Step 4: Look at the PaO2 and FiO2
Step 5: Integrate the Clinical Findings and ABG Data
SECTION 15: OPERATIVE OBSTETRICS
CHAPTER 75:
Operative Obstetrics
PREOPERATIVE CARE
PROCEDURES
Operation Notes
Postoperative Care
Checklist for Universal Precautions
PROCEDURES
1. Paracervical Block (Fig. 75.1)
Indications
Contraindication
Requirements
Procedure
Dangerous Effects of Lignocaine
Management
2. Pudendal Block Anaesthesia
Indications
Requirements
3. Dilatation and Evacuation (D and E)
Indications
Procedure (Fig. 75.3)
Postoperative Orders Include
Complications
4. Suction Evacuation
Indications
Procedure
Complications
Late Complications
5. Menstrual Regulation
6. Manual Vacuum Aspiration (See in Textbook of Gynaecology by Sudha Salhan)
7. Hysterotomy
Indications
Steps–
Complications
8. Episiotomy (Perineotomy) (Figs 75.6A to D)
Indications
Anaesthesia (Fig. 75.7)
Timing of Episiotomy
Types: Four types of episiotomies can be given
Timing of Repair
Technique (Mediolateral episiotomy)
Complications
9. Version
Types
EXTERNAL CEPHALIC VERSION (ECV)
Time of Version
Contraindications to ECV
Prerequisites for ECV
Success Rate
Dangers of ECV
Technique of ECV
Preparation
Procedure (Figs 75.8A and B)
ECV under Anaesthesia
ECV with Foetal Acoustic Stimulation
ECV with Tocolysis
Spontaneous Version
Internal Version
Indication
Prerequisites
Contraindications
Procedure
10. Culdocentesis (Fig. 75.10)
Colpotomy Indication Pelvic Abscess (Fig. 75.11) Cutting Open Pouch of Douglas (POD)
CHAPTER 76:
Obstetric Forceps and Ventouse
OBSTETRIC FORCEPS
Definition of Forceps
The Instrument
The Blade
The Shank
The Lock
The Handle
Indications for Forceps Delivery
Foetal Indication
Maternal Indications
Prolonged Second Stage
Contraindications of Forceps Delivery
Types of Forceps Application (Fig. 76.4)
Outlet Forceps
Low Forceps
Mid-Forceps
High Forceps
Pelvic versus Cephalic Application
Conditions to be fulfilled before the application of forceps:
Technique of Forceps Application
Preliminaries
Pudendal Block Anaesthesia
Application Procedure (Fig. 76.5)
Readjustment of Blades
For low forceps application with sagittal suture in oblique diameter
Trial of Forceps versus Failed Forceps
Causes of difficulty in forceps application:
Complications
Medicolegal Aspects
A MODEL OF CASE RECORD
VENTOUSE (VACUUM EXTRACTOR) (FIGS 76.8A TO F)
Definition
Instrument
Suction Cups
Suction Machine (Fig. 76.8 A and B)
Indications
Contraindications
Procedure of Ventouse Extraction
Application of the Cup (Fig 76.9)
Creation of Vacuum
Traction
Cup Pop-off
Complications
Mother
Newborn
Skills and Responsibilities
Prerequisites of Forceps and Ventouse Delivery
CHAPTER 77:
Female Sterilization, Caesarean Delivery and Other Emergency Obstetric Operations
METHOD USED PER ABDOMINALLY
ELIGIBILITY CRITERIA FOR FEMALE STERILIZATION (CASE SELECTION)
WHO Medical Eligibility Criteria for Female Sterilization (2004)
Following pregnancy conditions to be treated and resolved before operation
Conditions that increase surgical difficulties and risk
COUNSELLING
TECHNIQUES
CAESAREAN DELIVERY
History of Caesarean Delivery
Historical Advances
Incidence
Indications
Foetal Indications
Maternal Foetal Indications
Maternal Indications
Time of Operation in Caesarean Delivery
Types of Caesarean Section
Technique for Caesarean Delivery
Abdominal Incision
Transverse Incision
Uterine Incisions
Technique for Transverse Caesarean Incision
Delivery of the Infant
Repair of the Uterus
Abdominal Closure
Intraoperative Complications
Postoperative Complications
Remote Complications
Classical Caesarean Section
Indication
Steps
Perimortem Caesarean Section
Repair of Ruptured Uterus
PERIPARTUM HYSTERECTOMY (FIG. 77.7A TO C)
Indications
Technique
Steps
Repair of Cervical Tear
Aetiology
Treatment
Suture Used for Repair
Perineal Tear
Defect of Perineal Tear is Classified into Four Degrees
Repair
Third Degree and Fourth Degree Tears
Postoperative Management of Third Degreeand Fourth Degree Tear Repair
Postpartum Haemorrhage (PPH)
Uterine Artery Ligation (Fig. 77.10)
Technique
Postoperative Care
Internal (Hypogastric) Artery Ligation (Fig. 77.11)
Indication
Technique
Lynch Brace Suture (Figs 77.12A to C)
Technique
SELECTIVE ARTERIAL EMBOLISATION
Bladder Injury and its Repair
Cervical Encirclage
Other Procedures Used in Obstetric Practice
Amniotomy or Artificial Rupture of Membranes (ARM)
Contraindications
Prerequisites
Procedure
Complications
Urethral Catheterisation
Procedure
Dinoprostone Gel Instillation (Fig. 77.13)
Indications
Relative Contraindications
Absolute Contraindications
Adverse Reactions
Dosage
Prerequisites
Steps
Manual Removal of Placenta (Fig. 77.16)
Z- technique (Fig. 77.17) for Injection of Iron Preparations
Procedure
Venesection (Figs 77.18A to C)
Indications
Venepuncture
Complications
CENTRAL VENOUS PRESSURE (CVP)
Central Venous Pressure Catheters and Insertion Sites
Central Venous Pressure Line Site Care
Central Venous Pressure Monitoring
Central Venous Pressure Line Removal
CHAPTER 78:
Shoulder Dystocia
DEFINITION
FOETAL COMPLICATION
Aetiology
Prevention
Management
CHAPTER 79:
Destructive Operations
INTRODUCTION
DEFINITION
Scope of Destructive Operations
Types of Destructive Operations
Indications
Prerequisites
Instruments
PREOPERATIVE MEASURES
Anaesthesia
Decompression of Hydrocephalic Head
Craniotomy
Evisceration
Decapitation (Fig. 79.3)
Cleidotomy
Spondylotomy
COMPLICATIONS OF DESTRUCTIVE OPERATION
CONCLUSION
CHAPTER 80:
Shock in Obstetrics
SHOCK
Types and Causes of Shock in Obstetrics
Haemorrhagic Shock
Phase of Compensation
Phase of Decompensation
Phase of Cellular Damage and Danger of Death
Complications of Haemorrhagic Shock
Endotoxic Shock (Septic or Bacteraemia)
Causative Organisms
Pathology
Causes
Clinical Features
Management
Cardiogenic Shock
Clinical Features
Management
Neurogenic Shock
SECTION 16: REPRODUCTIVE AND CHILD HEALTH
CHAPTER 81:
Maternal Mortality and Approach to Its Review
INTRODUCTION
MATERNAL DEATHS
Definition
Direct Maternal Deaths
Indirect Maternal Deaths
Incidence
Why Do Mothers Die?
Three Delays
Interventions to Prevent Maternal Deaths
Antenatal Care and the “At Risk Approach”
Preventing Unwanted Abortions and Unsafe Abortions
Training Traditional Birth Attendants
Ensuring Skilled Attendance at Birth
Instituting Maternal Death Reviews
Community Based Maternal Death Reviews (Verbal autopsies)
Prerequisites
Advantages
Disadvantages
Facility Based Maternal Deaths Reviews
Prerequisite
Advantages
Disadvantages
Confidential Enquiries into Maternal Deaths
Prerequisite
Advantages
Disadvantages
Surveys of Severe Morbidity (Near Miss)
Definition
Prerequisites
Advantages
Disadvantages
Clinical Audit
Definition
Prerequisites
Advantages
Disadvantages
INITIATION OF FACILITY BASED REVIEW
OPERATIONALISING THE REVIEW
ANALYSIS OF MATERNAL DEATHS USING FACILITY BASED REVIEWS
LESSONS LEARNT
CONCLUSION
CHAPTER 82:
Rural Problems of Obstetrics
INTRODUCTION
The Maternal and Perinatal Morbidity and Mortality
Problems of Rural Areas
Role of TBA
Communication and Transport
Social Problems
The Role of the Mother Herself, Family Members and Community
Gender Discrimination and Son-Preference
Men's Responsibility
Role of Medical and Paramedical Personnel
CONCLUSION
CHAPTER 83:
Reproductive Morbidity
REPRODUCTIVE HEALTH
WOMEN'S MORBIDITY
REPRODUCTIVE MORBIDITY
Duration
Time of Onset
Accumulation
Sequel
Social
Complications of Pregnancy and Childbirth
Acute Maternal Morbidity
Chronic Maternal Morbidity
Obstetric Maternal Morbidity
Direct Obstetric Morbidity
Indirect Obstetric Morbidity
Psychological Disorders
Non Obstetric Morbidity
CHAPTER 84:
Reproductive and Child Health
INTRODUCTION
Concept of Reproductive Health
Reproductive and Child Health (RCH)
Components of RCH
RCH II
Strategies
Other Recommendations
Community Mobilisation Strategies
Strategies at Community Level
Strategies at Facility Level
SECTION 17: RADIOLOGIC INVESTIGATION IN OBSTETRICS
CHAPTER 85:
Ultrasound in Obstetrics
BASIC PHYSICS
TRANSDUCERS
Indications for First Trimester Ultrasound
Complications
Ectopic Pregnancy
Clinical Features
Ultrasound Findings
Chronic Ectopic Pregnancy
Second Trimester
Third Trimester
Normal Foetal Anatomy
Perinatal Diagnosis of Anomalies
Nuchal Translucency (NT) (Figs 85.19 to 85.24)
Major Anomalies
CNS: Anencephaly (Fig 85.25), hydrocephalus (Fig 85.26), meningomyelocele (Fig 85.27)
Syndromes
Placenta
Placenta Praevia
Retroplacental Haemorrhage
Placental Calcification (Fig. 85.32)
Placental Grading (Grannum's grading)
Foetal Biometry
Some Principles of Foetal Biometry
Crown Rump Length (CRL)
Biparietal Diameter
Abdominal Circumference
Intrauterine Growth Restriction (IUGR)
Evaluation of IUGR
Foetal Biophysical Profile
Foetal Doppler
Uterine Artery
Foetal Middle Cerebral Artery (MCA)
Umbilical Artery
CHAPTER 86:
Colour Doppler Applications in Obstetrics
EARLY PREGNANCY AND ECTOPIC PREGNANCY
FOETAL DEVELOPMENTAL ANOMALIES
UTERINE ARTERY FLOW VELOCITY WAVEFORMS
FOETAL HYPOXIA AND ACIDOSIS
MULTIPLE GESTATIONS
CONCLUSION
CHAPTER 87:
Magnetic Resonance Image (MRI) in Obstetric Practice
INDICATIONS OF MRI IN OBSTETRICS
COMPUTED TOMOGRAPHY IN OBSTETRICS
SECTION 18: HOSPITAL MANAGEMENT
CHAPTER 88:
Biomedical Waste Management and Handling Rules 1998
BIOMEDICAL WASTE MANAGEMENT AND HANDLING RULES 1998
Biomedical Waste Treatment Facility
Segregation, Packing, Transport and Storage
Segregation, Packing, Transportation and Storage of Biomedical Waste (Fig. 88.4)
Notes
Do's
Universal Precautions
CHAPTER 89:
Instruments in Obstetrics
OBSTETRIC FORCEPS
Wrigley's Forceps (Fig. 89.1)
Simpson's Long Forceps (Fig. 89.2)
Simpson's Short Forceps (Fig. 89.3)
Haig Ferguson's Forceps (Fig. 89.4)
KN Das' Forceps (Fig. 89.5)
Kielland's Forceps (Fig. 89.6)
Piper's Forceps (Fig. 89.7)
OTHER INSTRUMENTS USED IN OBSTETRIC PRACTICE
Sponge Holding Forceps (Fig. 89.8)
Artery Forceps (Fig. 89.9)
ABDOMINAL RETRACTOR
Daever's Retractor (Fig. 89.10)
Balfour Abdominal Retractor (Fig. 89.11)
GREEN ARMYTAGE UTERINE CLAMP (FIG. 89.12)
EPISIOTOMY CUTTING SCISSORS (FIG. 89.13)
UMBILICAL CORD CUTTING SCISSORS (FIG. 89.14)
VACUUM EXTRACTOR (FIGS 89.15 TO 89.17)
Traction Handle
Advantage of Ventouse Over Forceps
Advantage of Forceps Over Ventouse
Causes of Failure
Complications
INSTRUMENTS FOR DESTRUCTIVE OBSTETRICS OPERATION
Cranioclast (Fig. 89.18) (German: kranion, skull; klao, to break in pieces)
Cephalotribe (Fig. 89.19) (German: kephale, the head; tribo, to bruise)
Indication
Crochet (Fig. 89.20) (French: croche, hook)
Perforator (Fig. 89.21)
Technique of Perforation
Blond-Heidler Decapitation Saw (Fig. 89.22)
DEBDAS CRANIAL PERFORATOR
Pinard's Foetoscope (Figs 89.24A and B)
Doptone (Figs 89.25A and B)
Cardiotocograph (Fig. 89.26)
CHAPTER 90:
Obstetrics in Specimens
ANENCEPHALY (FIG. 90.1)
HYDATIDIFORM MOLE (FIG. 90.2)
Physical Signs
Complete Mole
RUPTURE UTERUS (Fig. 90.3)
Commonly Asked Questions in Final Year MBBS Examination
NORMAL LABOUR
MEDICAL DISORDER IN PREGNANCY
ABNORMAL PUERPERIUM
INJURIES AND FEMALE GESTATION
MALFORMATIONS OF FEMALE GENERATING ORGANS
MISCELLANEOUS
NEONATOLOGY
BREAST
NEONATAL PREGNANCY
MATERNAL MORTALITY
SPECIAL CASES IN OBSTETRICS
Recently Asked Questions in Various MD/MS Entrance Examination
PHYSIOLOGICAL CHANGES IN PREGNANCY
DIAGNOSIS IN PREGNANCY
FOETUS-IN-UTERO, FOETAL SKULL AND MATERNAL PELVIS
FOETAL WELL BEING: ANTENATAL ASSESSMENT
NORMAL LABOUR
NORMAL PUERPERIUM
HYPEREMESIS GRAVIDARUM
HAEMORRHAGE IN EARLY PREGNANCY
ECTOPIC PREGNANCY
H. MOLE
MULTIPLE PREGNANCY
APH
GYNAECOLOGICAL DISORDERS IN PREGNANCY
POST MATURITY AND IUD
SPECIAL CASES
CONTRACTED PELVIS
ABNORMAL UTERINE CONTRACTION
FOETAL ANOMALIES
COMPLICATIONS OF III STAGE OF LABOUR
ABNORMALITIES OF PUERPERIUM
PHARMACOTHERAPEUTICS
OPERATION OBSTETRICS
CTG
MEDICAL ILLNESS
Complications of Third Stage of Labour
DEFINITION
1. POSTPARTUM HAEMORRHAGE (PPH)
Placental causes
Traumatic causes
Coagulation defects foetal
Prevention
Placental causes
2. RETAINED PLACENTA
3. ADHERENT PLACENTA
Placenta Accreta, Increta and Percreta
Incidence and Risk Factors
Presentation/Diagnosis
4. TRAUMATIC PPH
Repair of third and fourth degree perineal tear
Essential steps involve
Uterine rupture
5. PUERPERAL HAEMATOMAS
Presentation
Management
6. UTERINE INVERSION
7. SECONDARY PPH
Conclusions
INDEX
TOC
Index
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