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Manual for Obstetrics & Gynecology Practitioners
Suchitra N Pandit, Reena J Wani, Gorakh G Mandrupkar, Madhuri Mehendale, Rakhee R Sahu
SECTION 1: COMMON GYNECOLOGICAL COMPLAINTS—ALGORITHMS
1:
Vaginal Discharge
VAGINAL FLORA
Physiological
Pathological
Physiological Vaginal Discharge
PATHOLOGICAL CAUSES
HISTORY
EXAMINATION
LABORATORY INVESTIGATIONS
SEXUALLY TRANSMITTED INFECTION TESTING
HIGH VAGINAL SWABS
MICROSCOPY
Culture
Criteria for Diagnosis of Bacterial Vaginosis (Evidence Level II, Grade B)9–11
Criteria for Diagnosis of Vaginal Candidiasis (Evidence Level III, Grade B)12
Criteria for Diagnosis of Trichomonasis Vaginalis (TV) (Evidence Level III, Grade B)13,14
MANAGEMENT
Indications for Referral to Genitourinary Medicine
BACTERIAL VAGINOSIS
VULVOVAGINAL CANDIDIASIS
TRICHOMONAS VAGINALIS
Recommended Regimens for T. vaginalis and Bacterial Vaginosis (Evidence Level Ia, Grade A)19–21
Alternative Regimens for Bacterial Vaginosis Only
Recommended Regimens for Vaginal Candidiasis (Level of Evidence II, Grade A)22,23
Manangement of Vaginal Discharge in Special Circumstances
Recurrent Vaginal Discharge
Recurrent Bacterial Vaginosis
Recurrent Vulvovaginal Candidiasis
Recurrent Tricomonas Vaginalis
CONCLUSION
2:
Dysmenorrhea
PREVALENCE
PATHOPHYSIOLOGY OF DYSMENORRHEA
SYMPTOMATOLOGY
SEVERITY OF DYSMENORRHEA
TYPES OF DYSMENORRHEA
EVALUATION OF A CASE OF DYSMENORRHEA
HISTORY
Pelvic Examination
Pelvic Ultrasound
MANAGEMENT
ANALGESICS
Nonsteroidal Anti-Inflammatory Drugs
Advantages
Disadvantages
Contraindications
COX2 Specific Inhibitors
Other Analgesic Agents
ORAL CONTRACEPTIVES
LEVONORGESTREL-RELEASING INTRAUTERINE SYSTEM
OTHER TREATMENT OPTIONS
Progestogens and Antiprogestogens
Gonadotropin-releasing Hormones and Danazol
Calcium Channel Blockers
Alternative Therapies
Herbal Products or Medicines and Dietary Supplements
Dietary Changes
Exercise
Transcutaneous Electrical Nerve Stimulation (TENS)
Acupuncture
Heat
Surgery
FUTURE PROSPECTS IN THE MANAGEMENT OF DYSMENORRHEA
Vasopressin Antagonists
Nitroglycerin
Magnets
Current Research
TIPS FOR GENERAL PRACTITIONERS1
3:
Menorrhagia
INTRODUCTION
DEFINITION
ASSESSMENT AND INVESTIGATION
Assessment of Menstrual Blood Loss
Pattern of Menstrual Blood Loss
Pelvic Examination
Full Blood Count
Thyroid Function Test
Assessment of Endometrium
Ultrasound
Hysteroscopy and Endometrial Biopsy
MANAGEMENT
Medical Treatment
Nonsteroidal Anti-inflammatory Drugs
Combined Oral Contraceptive Pills
Antifibrinolytic Agents
Danazol
Progestogens
Levonorgestrel Intrauterine System
GnRH agonists
Surgical Management
Medical versus Surgical Treatment
Dilatation and Curettage
Endometrial Destruction
Hysterectomy
RECOMMENDATIONS
MEDICAL TREATMENT
SURGICAL MANAGEMENT
4:
Amenorrhea
INTRODUCTION
EVALUATION OF AMENORRHEA (FLOW CHART 2)
Step I
Step II
Step III
Causes of Primary Amenorrhea
MANAGEMENT
5:
Pelvic Infection
INTRODUCTION
DEFINITION
INCIDENCE AND PREVALENCE
ETIOLOGY AND PATHOPHYSIOLOGY
PROTECTIVE MECHANISMS OF THE VAGINAL FLORA
COMMON ORGANISMS CAUSING PID8
PATHOLOGY
CLINICAL FEATURES9
COMPLICATIONS
Fitz-Hugh–Curtis Syndrome
DIAGNOSIS (TABLE 1)
DIFFERENTIAL DIAGNOSIS12
MANAGEMENT (FLOW CHART 2)
CRITERIA FOR OUTPATIENT TREATMENT13
Outpatient Therapy13
Alternative Oral Regimen
Parenteral Treatment13
Alternative Parenteral Regimen
CRITERIA FOR HOSPITALIZATION13
SPECIAL CASES
Allergy9
Pregnancy and Lactation12
Intrauterine Contraceptive Device and PID13
Adolescents
HIV9
PID during Pregnancy13
SURGICAL MANAGEMENT1
Indications
Type of Surgery
SEXUAL PARTNERS13
FOLLOW-UP13
Follow-up for Moderate/Severe PID At 72 hours
Follow-up for Mild PID: 1–2 week
POSTEXPOSURE PROPHYLAXIS OF STI4
FAQS
STI (Genital infections) Checklist
For Men
For Women
High Risk Sexual Behavior
STI History
STI Treatment History
SYNDROMIC APPROACH BY WHO14
PREVENTION
CONCLUSION
6:
Ectopic Pregnancy—An Insight
INTRODUCTION
SITES OF ECTOPIC PREGNANCY
RISK FACTORS ASSOCIATED WITH ECTOPIC PREGNANCY2,3
High Risk Factors
Moderate Risk Factors
Low Risk Factors
Potential Outcomes
CLINICAL FEATURES
Symptoms
Signs
DIAGNOSIS (FLOW CHART 1)
TREATMENT
Treatment Options
Medical Therapy vs Surgical Treatment6
Serum βhCG Values
Medical Therapy
Whom to Administer
Modes of Administration
Treatment Protocol (Table 2)
Contraindications to MTX
Other Agents for Medical Therapy
Indications for Surgery (MTX Failure)
SURGICAL MANAGEMENT
Surgical Procedure Options
EXPECTANT MANAGEMENT
PERSISTENT TROPHOBLAST
RARE TYPES OF ECTOPIC PREGNANCY
Abdominal Pregnancy
Ovarian Pregnancy
Cervical Pregnancy
Cornual or Interstitial Pregnancy
Intraligamentous Pregnancy
Cesarean Scar Pregnancy
SUMMARY POINTS
7:
Infertility
INTRODUCTION
COUNSELING OF THE COUPLE
CAUSES OF INFERTILITY
Male Infertility
Causes of Male Infertility
Diagnosis
Investigations
Treatment Options
Assisted Reproduction
Female Infertility
Causes of Female Infertility
Tubal Surgery
Uterine Surgery
Medical and Surgical Management of Endometriosis (Fig. 1)
UNEXPLAINED INFERTILITY
Ovarian Stimulation for Unexplained Infertility
Intrauterine Insemination (Fig. 2)
MANAGEMENT OF INFERTILE COUPLE OR WOMAN13
TREATMENT
Female Factor (30–50%)
Male Factor
Unexplained Infertility
8:
Genital Prolapse (Pelvic Organ Prolapse)
INTRODUCTION
ETIOLOGY
ANATOMICAL CONSIDERATIONS
CLASSIFICATION
MANAGEMENT OF UTERINE PROLAPSE
Conservative
Surgical Method
SURGICAL OPTIONS WITH HYSTERECTOMY
Anterior Compartment Repair (Cystocele)
Posterior Compartment Repair (Rectocele)
Enterocele
Vault Prolapse
Recurrent Prolapse
Obliterative Surgeries
9:
Perimenopausal Abnormal Uterine Bleeding
INTRODUCTION
PHYSIOLOGY OF MENSTRUATION DURING PERIMENOPAUSE
PATHOLOGY OF MENSTRUATION DURING PERIMENOPAUSE
DEFINITIONS
CLASSIFICATION (FIG. 1)
EVALUATION OF WOMAN WITH ABNORMAL BLEEDING
History
Examination
Investigations
Cervical and Vaginal Swabs
Imaging and Hysteroscopy
Endometrial Sampling and Biopsy
Hysteroscopy
TREATMENT
Medical Treatment
CONCLUSION
KEY POINTS
10:
Postmenopausal Bleeding
DEFINITION
INCIDENCE AND RISK FACTORS
EVALUATION OF POSTMENOPAUSAL BLEEDING
Bleeding in Special Circumstances
MANAGEMENT
SOGC Recommendation for Screening of Endometrial Cancer10
CONCLUSION
SECTION 2: CONTRACEPTION, ABORTION AND FAMILY WELFARE—CHECKLISTS
11:
Adolescents and Contraception
INTRODUCTION
IMPACT OF UNPROTECTED SEX IN ADOLESCENCE
FACTORS AFFECTING CONTRACEPTIVE USAGE
COUNSELING ADOLESCENTS FOR CONTRACEPTION
METHODS OF CONTRACEPTION
Barrier Methods of Contraception
Male and Female Condoms
Female Condom
Vaginal Spermicide
Hormonal Contraception (Flow Chart 1)
Combined Estrogen Progesterone Pill
Extended Cyclic Pills
Noncontraceptive Benefits for OCP in Adolescents
Progestogen-only Pill (POPs)
Injectable Hormonal Contraception
Other Combined Hormonal Contraceptive Methods
Emergency Contraception
Long-acting Reversible Contraceptives
Progestin Implants
Intrauterine Devices
Postpartum and Postabortal LARC
FOLLOW-UP
SUMMARY
12:
Emergency Contraception
INTRODUCTION
INDICATIONS
TYPES OF EC AND THEIR MECHANISM OF ACTION
MANAGEMENT OF A REQUEST FOR EMERGENCY CONTRACEPTION
Patient History
Examination
Side-effects
Follow-up
Effectiveness
FREQUENTLY ASKED QUESTIONS
REGULATORY ASPECTS
EMERGENCY CONTRACEPTION IN VARIOUS GLOBAL REGIONS
USA and Plan B
Europe
Asia
13:
Medical Abortion
INTRODUCTION
MEDICAL METHODS OF ABORTION
Mechanism of Action
Misoprostol
What is the Gestation Limits?
How Safe is the MMA?
Failure Rate
Who can Prescribe Medication for MMA?
Where can the Medication be Prescribed?
Advantages of MMA
Disadvantages of MMA
Indications
Contraindications
Preabortion Counseling
Role of Ultrasonography
Clinical Protocol
Adjuvant Medications
Complications and Management
Follow-up and Post-abortion Contraception
Maintenance of Records
Consent Form
14:
Surgical Abortions
INTRODUCTION
PREOPERATIVE ASSESSMENT
DILATATION OF THE CERVIX
ANALGESICS AND ANESTHETICS
PROPHYLACTIC ANTIBIOTICS
SUCTION AND EVACUATION PROCEDURE
SUSPECTED PERFORATION
INCOMPLETE ABORTION
POSTABORTAL CONTRACEPTION
15:
Female Sterilization
INTRODUCTION
CLIENT ELIGIBILITY CRITERIA/CASE SELECTION2,3
WHICH METHOD?
PREPARATION AND PROCEDURES
Timing of the Surgical Procedure
COUNSELING2,3
CLINICAL ASSESSMENT AND SCREENING OF CLIENTS4,6
CONTRAINDICATIONS AND CRITERIA2,5,9
CONCLUSION
16:
Male Sterilization
INTRODUCTION
COUNSELING
MEDICAL ELIGIBILITY CRITERIA OF MALE STERILIZATION1
Case Selection
Techniques
CONVENTIONAL VASECTOMY
Preoperative Preparation
Anesthesia
Surgical Procedure for Occlusion of the Vas (Figs 1A and B)
NO SCALPEL VASECTOMY
Instruments Needed (Fig. 2)
Preoperative Preparation
Anesthesia (Fig. 4)
Surgical Procedure for Occlusion of the Vas
Scalpel Versus No-scalpel Incision for Vasectomy2
Postoperative Advice
FAILURE3
SUMMARY
17:
Understanding Preconception and Prenatal Diagnostic Techniques Act
INTRODUCTION
WHY TO KNOW ABOUT PCPNDT ACT?
DO’S AND DON’TS ABOUT PCPNDT ACT
Do's in PCPNDT Act
Don'ts in PCPNDT Act
SUMMARY
18:
Preconception Planning
INTRODUCTION
AIM OF PRECONCEPTION PLANNING
WHO SHOULD DO IT?
WHAT SHOULD BE DONE AT THE PRECONCEPTION VISIT?
History
Examination
Investigations
Documentation
Advice
WHO SHOULD BE REFERRED TO A SPECIALIST?
EVIDENCE
CONCLUSION
19:
Screening for Chromosomal Abnormalities
INTRODUCTION
GENETIC COUNSELING
Things to Keep in Mind
WHAT DISORDERS ARE BEING SCREENED FOR?
Down Syndrome (Trisomy 21)
Edwards Syndrome (Trisomy 18)
Patau Syndrome (Trisomy 13)
Neural Tube Defects
SERUM MARKERS
First Trimester Screening
Beta Human Chorionic Gonadotropin
Pregnancy-associated Plasma Protein A (PAPPA)
Second Trimester Screening
The Triple and Quadruple Screen Tests (Table 1)
Inhibin A
INTEGRATED TEST
SEQUENTIAL TEST
Ultrasound Markers of Chromosomal Anomalies
Nuchal Translucency (Fig. 2)
Nasal Bone Hypoplasia (Fig. 3)
Nuchal Pad Edema
Echogenic Bowel (Fig. 4)
Echogenic Focus in the Heart (Golf Ball Sign) (Fig. 5)
Choroid Plexus Cysts (Fig. 6)
Mild Ventriculomegaly (Fig. 7)
Disadvantages of Soft Markers
CELL-FREE DNA—NONINVASIVE PRENATAL TEST
Diagnostic Tests
Indications for Invasive Testing
CONCLUSION
SECTION 3: HIGH-RISK PREGNANCIES—PROTOCOLS
20:
Anemia in Pregnancy
INTRODUCTION
DEFINITION
CAUSES OF ANEMIA IN PREGNANCY
Acquired
Hereditary
EFFECTS OF ANEMIA ON PREGNANCY
EFFECTS OF PREGNANCY ON ANEMIA
IRON DEFICIENCY ANEMIA
DIAGNOSIS OF IRON DEFICIENCY
Clinical Symptoms and Signs
LABORATORY EVALUATION
Full Blood Count, Blood Film and Red Cell Indices
Serum Ferritin
Other Tests
TREATMENT
Prophylactic
Family Planning Advice
Dietary Advice
Supplementary Iron Therapy
Therapeutic
PARENTERAL IRON THERAPY
Indications for Blood Transfusion
Postpartum/Postnatal Period
Management of Delivery in Women with Iron Deficiency Anemia
MEGALOBLASTIC ANEMIA
Clinical Features
Investigations
Complications
Treatment
Prophylactic
Curative
21:
Hypertensive Disorders in Pregnancy: Clinical Approach
INTRODUCTION
DEFINITION
CLASSIFICATION OF HDP
Types Based on Proteinuria6
Severity Classification
Classification Based on Time of Onset during the Gestation
MANAGEMENT OF HDP
Maternal Surveillance HDP
Fetal Surveillance HDP
Acute Management of Severe Hypertension
Seizure Prophylaxis
Antenatal Steroids
Consultations and Referrals
Expectant Management
Decision to Deliver
Delivery Considerations
Induction of Labor
Route of Delivery
Fluid Management
Prevention of Complications
Anesthesia and Analgesia
Active Management of Third Stage of Labor (AMTSL)
POSTPARTUM CARE
PREDICTION AND PREVENTION
RISK FACTORS: TO ASSESS AT THE FIRST ANTENATAL VISIT OF ALL PATIENTS
Early Diagnosis of Preeclampsia
Long-term Sequel
Fetal Effects
Recurrence in Succeeding Pregnancies
Prevention
22:
Gestational Diabetes Mellitus
CLINICAL SITUATION
DEFINITION
IS IT COMMON IN OUR COUNTRY?
SHOULD WE SCREEN ALL ANTENATAL PATIENTS FOR GDM?
WHEN TO SCREEN?
WHICH SCREENING TEST IS EFFECTIVE AND DOABLE?
SHOULD WE BE TREATING GDM?
Treatment
HOW TO MONITOR SUGAR LEVELS?
PHARMACOLOGICAL THERAPY
Insulin
Oral Hypoglycemic Agents
ANTEPARTUM MANAGEMENT
COMPLICATIONS
MONITORING THE PREGNANCY
Delivery
Timing of Delivery
Mode of Delivery
Intrapartum Care
Care of the Newborn
Postpartum Follow-up
Interpretation
Contraception
23:
Cardiac Diseases in Pregnancy
INTRODUCTION
FUNCTIONAL CLASSIFICATION OF HEART FAILURE4
Preconceptional Counseling
Antepartum
Intrapartum Care
GENERAL MANAGEMENT OF CARDIAC PATIENTS IN LABOR
Patient Care
Postpartum Care
Contraception
RHEUMATIC HEART DISEASES/VALVULAR HEART DISEASES
Mitral Valve Stenosis
Arortic Stenosis
Mitral Valve Regurgitation and Prolapse
CONGENITAL HEART DISEASES
Tetralogy of Fallot
Transposition of the Great Arteries (TGA)
AORTIC DISSECTION
CORONARY ARTERY DISEASE
CARDIOMYOPATHIES
ARRHYTHMIA
24:
Bad Obstetric History
BACKGROUND AND DEFINITIONS
ETIOLOGY
GENETIC FACTORS
AUTOIMMUNE FACTORS
Systemic Lupus Erythematosus (SLE)
Antiphospholipid Antibody Syndrome
Thrombophilias
ALLOIMMUNE FACTORS
ENDOCRINE FACTORS
ANATOMIC ABNORMALITIES
CERVICAL INCOMPETENCE
INFECTIONS
ENVIRONMENTAL FACTORS
Isotretinoin
Anesthetic Gases
Smoking
Alcohol
Caffeine
UNEXPLAINED RECURRENT PREGNANCY LOSS
25:
Previous Cesarean Section
INTRODUCTION
TERMINOLOGY
Planned VBAC
Successful VBAC
Unsuccessful Planned VBAC
Maternal Outcomes
ANTENATAL COUNSELING
FACTORS ASSOCIATED WITH SUCCESSFUL VBAC1
RISK FACTORS FOR UNSUCCESSFUL VBAC1
Contraindications to VBAC1
SPECIFIC RISKS OF VBAC1
BENEFITS OF VBAC3
RISKS OF ERCS1
PARAMETERS FOR DECIDING VBAC
PLANNED VBAC IN SPECIAL CIRCUMSTANCES
INTRAPARTUM CARE DURING PLANNED VBAC
PATHOGNOMIC CLINICAL FEATURES INDICATIVE OF UTERINE RUPTURE1
SECOND STAGE
THIRD STAGE
INDUCTION AND AUGMENTATION
SECOND TRIMESTER DELIVERY OR DELIVERY OF AN INTRAUTERINE FETAL DEMISE3
TIMING OF ELECTIVE CESAREAN SECTION
PREOPERATIVE
ANESTHESIA
INTRAOPERATIVE
PROBLEMATIC SCENARIOS
Placenta Previa
Diagnosis and Management of Morbidly Adherent Placenta1
Immediate Postoperative Care
26:
Rh Isoimmunization
INTRODUCTION
PREVALENCE
PATHOPHYSIOLOGY
PREVENTION
DIAGNOSTIC APPROACH
Genetics
Maternal Titer
Middle Cerebral Artery Doppler
Amniocentesis
Fetal Blood Sampling
Summary of Clinical Management
First Affected Pregnancy
Previously Affected Fetus or Infant
THERAPEUTIC APPROACH
Intrauterine Transfusion
CONCLUSION
27:
Growth Restricted Fetus
INTRODUCTION
DEFINITION
PHYSIOLOGY OF FETAL GROWTH
TYPES OF FETAL GROWTH RESTRICTION
Symmetric Growth Restricted Fetus
Asymmetric Growth Restricted Fetus
Constitutional Small Fetus
ETIOLOGY OF FETAL GROWTH RESTRICTION
MATERNAL DISORDERS
Maternal Medical Disorders
FETAL DISORDERS
Placental and Cord Abnormalities
Multiple Pregnancy
IDENTIFICATION OF RISK FACTORS FOR PREDICTING FGR
Biochemical Markers for Prediction of FGR
Screening for FGR by Uterine Artery Doppler
Antenatal Diagnosis of Fetal Growth Restriction
Early Establishment of Gestational Age
CLINICAL ASSESSMENT FOR GROWTH
Ultrasound Diagnosis of SGA
Biometric Ratio
Customized/Population-based Growth Charts
Investigation to Identify Etiology
Fetal Anatomical Survey
Doppler for Diagnosis, Etiology and Surveillance
Umbilical Artery Doppler (UAD)
Middle Cerebral Artery Doppler Flow
Venous Doppler
PREVENTION
MANAGEMENT
Methods of Fetal Surveillance used in SGA Fetuses
Nonplacental-mediated FGR
Constitutional Small Fetus
Placental Insufficiency-mediated FGR
NEONATAL COMPLICATIONS
28:
Antepartum Hemorrhage
INTRODUCTION
DEFINITION
CAUSES
DEFINING THE SEVERITY
Fetal Death Implies
ASSESSMENT
Palpation
Speculum Examination
Digital Vaginal Examination
Ultrasound
Fetal Investigation
COMPLICATIONS
Maternal Complications
Fetal Complications
MANAGEMENT
Labor and Delivery
Third Stage Management
Rh Negative Mothers
Management of Third Trimester Bleeding (Flow chart 1)
Management of Abruptio Placentae (Flow chart 2)1
Management of Placenta Previa (Flow chart 3)1
Can We Predict
ABRUPTIO PLACENTAE
Predictive Markers Under Consideration
PLACENTA PREVIA
Risk Factors for Placenta Previa
VASA PREVIA
APT Test2
UNEXPLAINED APH
29:
Twin Pregnancy
DEFINITION
INCIDENCE
THE GENESIS OF TWINS
Diagnosis (Table 2)
Clinical Features (Table 2)
Role of Ultrasound in Determination of Chorionicity
NOMENCLATURE OF ULTRASOUND IN TWIN PREGNANCY
Role of Serial Transvaginal Assessment of Cervix
MATERNAL AND FETAL COMPLICATIONS (TABLES 4 AND 5)
Discordant Twins
Twin-to-Twin Transfusion Syndrome
Stuck Twin
Monoamniotic Twin
Single Fetal Demise
Congenital Anomalies
Acardiac Twinning
Umbilical cord problems
ANTENATAL MANAGEMENT
Antepartum Screening for Aneuploidy and Structural Anomalies
Nuchal Translucency
Chorionic Villus Sampling
AMNIOCENTESIS
Technique of Amniocentesis in Twin Pregnancy
Double Puncture Technique
Single Puncture Technique
Selective Termination of Pregnancy12
MANAGEMENT DURING LABOR (FLOW CHART 1)
Delivery of the First Twin
Delivery of the Second Twin
Management of the Third Stage of Labor
Cesarean Section Delivery
Locking of Twins
CONCLUSION
30:
Fever in Pregnancy and Postpartum Period
INTRODUCTION
INVESTIGATIONS
TREATMENT
Second and Third Trimesters
Lactating Women
31:
Liver Diseases in Pregnancy
INTRODUCTION
LIVER DISEASES UNIQUE TO PREGNANCY
Hyperemesis Gravidarum
Intrahepatic Cholestasis of Pregnancy
Clinical Features and Diagnosis
Management
Preeclampsia
HELLP Syndrome
Incidence
Pathogenesis
Clinical Features and Diagnosis
Management
Role of Steroids
Complications
Acute Fatty Liver of Pregnancy
Clinical Features and Diagnosis
Management
LIVER DISEASES OCCURRING COINCIDENTALLY IN A PREGNANT PATIENT
Hepatitis B
Hepatitis C
Hepatitis E virus
Hepatitis A
Gallstones and Biliary Disease
Portal Hypertension
32:
HIV Infection in Pregnancy
INTRODUCTION
MAGNITUDE OF PROBLEM
MODE OF TRANSMISSION
EFFECTS OF HIV ON PREGNANCY
EFFECTS OF PREGNANCY ON HIV
Factors which Influence Risk of Mother-to-Child Transmission
PREVENTION OF PARENT-TO-CHILD TRANSMISSION PROGRAM
Essential Package of PPTCT Services2
MANAGEMENT OF HIV-POSITIVE PREGNANT WOMAN
Antenatal Care
Antiretroviral Therapy
SOME SITUATIONS
Pregnant Women Newly Initiating ART
Pregnant Women Already Receiving ART
ART Regimen for Pregnant Women having Prior Exposure to NNRTI for PPTCT
Women Presenting Directly-in-labor-screen
Pregnant Women with HIV2 Infection
INTRAPARTUM CARE
Precautions during Labor
Role of Elective LSCS
Cesarean Section Technique
POSTPARTUM CARE
Care of Neonate
Infant Feeding
Contraception
33:
Management of Rh-negative Pregnancy: A Practical Approach
INTRODUCTION
PREVENTION
DETECTION OF FETAL ANEMIA
CONCLUSION
SECTION 4: LABOR ROOM DRILLS
34:
Induction of Labor
INTRODUCTION
COMMON INDICATIONS FOR INDUCTION OF LABOR (WHO)
Induction of Labor in Women at or Beyond Term
Induction of Labor in Women with Prelabor Rupture of Membranes (PROM) at Term
Induction of Labor for Suspected Fetal Macrosomia
Induction of Labor in Gestational Diabetes Mellitus
Induction of Labor in Women with Uncomplicated Twin Pregnancy at or Near Term
METHODS OF CERVICAL RIPENING AND INDUCTION OF LABOR
Oxytocin for Induction of Labor at Term
Prostaglandins for Induction of Labor
Mechanical Methods for Cervical Dilatation and Induction of Labor
Sweeping Membranes for Induction of Labor
MISOPROSTOL FOR TERMINATION OF PREGNANCY IN WOMEN WITH A FETAL ANOMALY OR AFTER INTRAUTERINE FETAL DEATH
VAGINAL BIRTH AFTER CESAREAN SECTION (VBAC)
DOES INDUCTION OF LABOR INCREASE THE RISK OF CESAREAN SECTION?
CONCLUSION
35:
Partogram
INTRODUCTION
HISTORY AND EVOLUTION OF PARTOGRAM
Progress of Spontaneous Labor at Term
THE GRAPH SECTION OF COMPOSITE PARTOGRAM6
Progress of Labor
Cervical Dilatation
Descent of Fetal Head
Uterine Contractions
The Fetal Condition
Fetal Heart Rate
Liquor
Moulding
Maternal Condition
IMPORTANCE OF ALERT AND ACTION LINES
USE OF PARTOGRAM IN DIFFERENT RESOURCE SETTINGS
Abnormal Labor Patterns
NEWER CONCEPT IN PARTOGRAM
Paperless Partogram
CONCLUSION
36:
Problems in the Second Stage of Labor
INTRODUCTION
DEFINITION
AVERAGE DURATION OF THE SECOND STAGE
MONITORING THE SECOND STAGE—DETECTING PROBLEMS
STANDARD CARE IN THE SECOND STAGE OF LABOR
MATERNAL EXHAUSTION IN THE SECOND STAGE
NONREASSURING FETAL STATUS IN THE SECOND STAGE
DELAY IN THE SECOND STAGE
SAFE INSTRUMENTAL DELIVERY
SAFE CESAREAN SECTION IN THE SECOND STAGE
SHOULDER DYSTOCIA
FUTURE PREGNANCIES WITH A DIFFICULT SECOND STAGE IN THE PAST
37:
Operative Vaginal Birth
INTRODUCTION
INCIDENCE AND DELIVERY RATES
CLASSIFICATION OF INSTRUMENTAL DELIVERIES
INDICATIONS AND CONTRAINDICATIONS (TABLES 2 TO 4)
PREREQUISITES FOR OPERATIVE VAGINAL DELIVERY (TABLE 5)
CHOOSING FORCEPS VS VACUUM
STRUCTURE OF FORCEPS (FIG. 1)
TYPES OF FORCEPS
Classical Instruments (Figs 4 and 5)
Specialized Instruments
FUNCTIONS OF FORCEPS
TYPES OF APPLICATION OF FORCEPS BLADES
TRACTION WITH FORCEPS
‘ABCDEFGHIJ‘ MNEMONIC FOR FORCEPS
TECHNIQUE OF OUTLET FORCEPS
TRIAL OF FORCEPS
FAILED FORCEPS
OUTCOME AND PROGNOSIS
COMPLICATIONS
Maternal Complications
Fetal Complications
VACUUM OR VENTOUSE DELIVERY
USING THE ‘ABCDEFGHIJ‘ MNEMONIC FOR VACUUM DELIVERY (FIG. 22)
FETAL POSITION AND VACUUM-ASSISTED VAGINAL DELIVERY
USING FORCEPS FOLLOWING FAILED VACUUM DELIVERY
COMPLICATIONS OF VACUUM
Maternal Risks
Neonatal Risks
POST-DELIVERY CARE
TRAINING IN OPERATIVE VAGINAL DELIVERY
FUTURE OF OPERATIVE VAGINAL DELIVERY
38:
Breech Presentation
INTRODUCTION
ANTENATAL MANAGEMENT OF BREECH PRESENTATION
Procedure
Contraindications to ECV
MANAGEMENT OF VAGINAL BREECH DELIVERY4
General Principles
Delivery of Buttocks
Delivery of Trunk
Delivery of Head
ARREST OF BREECH IN PELVIC CAVITY
ARREST DUE TO EXTENDED LEGS
Pinard's Maneuver
Direct Traction
ARREST OF ARMS (EXTENDED OR NUCHAL DISPLACEMENT)
Direct Extraction of Extended Arm
Lovset's Maneuver5
Extraction with Blunt Hook
ARREST OF AFTERCOMING HEAD OF BREECH
Burns-Marshall Procedure (Fig. 1)
Mauriceau–Smellie–Veit Maneuver
Wigand–Martin–Winckel Maneuver
Prague Maneuver
Forceps for Aftercoming Head of Breech
DELIVERY OF BREECH DURING CESAREAN SECTION
COMPLICATIONS OF VAGINAL BREECH BIRTH9
WHAT IS NEW?
Term Breech Trial (Hannah 2000)
39:
Shoulder Dystocia
DEFINITION
OBJECTIVE DEFINITION
INCIDENCE
TYPES
RISK FACTORS6
PATHOPHYSIOLOGY
Fetal Macrosomia7
INDICATORS
Intrapartum Events
DIAGNOSIS
COMPLICATIONS
Fetal
Maternal
PREVENTION OF SHOULDER DYSTOCIA
GOALS OF MANAGEMENT (FIG. 2)
STEPS OF MANAGEMENT
40:
Cord Prolapse
INTRODUCTION AND INCIDENCE
ETIOLOGY
TYPES OF CORD PROLAPSE (FIG. 3)
DIAGNOSIS
MANAGEMENT
Primary Prevention
Early Diagnosis
Principles of Management
Handling the Cord
Bladder Filling
OUTCOME
INCIDENCE
MANAGEMENT
FETAL MORTALITY
41:
Eclampsia
INTRODUCTION
INCIDENCE
PATHOPHYSIOLOGY
ECLAMPTIC EVENTS
MANAGEMENT
Principles of Management
Magnesium Sulfate
Mechanism of Action
Side-effects
Pritchard Regimen6
Loading Dose
Maintenance Dose
Dose for Recurrence of Convulsion
Zuspan IV Regimen
Loading Dose
Maintenance Dose
Other Regimens
Antihypertensive Medicines
Delivery Decision
IV Fluids
CONCLUSION
42:
Postpartum Hemorrhage— Predict, Prepare and Handle
EPIDEMIOLOGY AND GROUND REALITIES
HOW TO MAKE LABOR WARD SAFE?
Location and Layout
Receiving Area/Triage Area
Handing Over Board
Charts
Personnel
Equipment
Monitoring
Others
Delivery Tray
Emergency Obstetrics Drug Kit
PPH DRUG KIT (to be Stored in the refrigerator)
Neonatal Resuscitation
Documentation
THE GOLDEN HOUR
Predict/Prepare/Handle
Being Prepared
Handling PPH
Steps in Resuscitation
Medication for Uterine Atony
Further Management
NONPNEUMATIC ANTISHOCK GARMENT
How does NASG Work (Fig. 4)?
How to Apply NASG?
How to Remove and Store the NASG?
Advantages of NASG
COMPONENT THERAPY IN OBSTETRICS
Fresh Whole Blood and Banked Whole Blood
Blood Components (Fig. 6)
Why do We Need to Transfuse Components and Not Whole Blood?
Aims of Transfusion
Preparing for Transfusion
How Urgent is the Blood?
When to Transfuse?
Postpartum Hemorrhage Algorithm
When to Stop the Transfusion?
BLOOD COMPONENTS
Packed RBC–PRBC
Platelets
Fresh Frozen Plasma
Indications
Cryoprecipitate
Indications
When you must Transfuse?
Massive Hemorrhage and MTP
Activation of Massive Transfusion Protocol
Conclusion
TAMPONADE IN PPH
Intrauterine Balloon Tamponade
How does it Work?
Balloons used in Tamponade
How to Perform Tamponade
At Cesarean Section
Shivkar's Condom Balloon Pack
Balloon vs Uterine Packing
Long-term Effects of Tamponade
Conclusion
SURGICAL MANAGEMENT OF PPH
Introduction
Causes
Management
HEMOSTASIS ALGORITHM
Surgical Management
Compression Sutures
B-Lynch Suture Technique
Clinical Points
Square Suture
Cho Stitch–Clinical Points
Modified B-Lynch Suture
Hayman Suture—Clinical Points
Isthmic Cervical Apposition Suture14
Uterine Artery Ligation
Utero-ovarian Artery Anastomosis Ligation
Internal Iliac Artery (Hypogastric Artery) Ligation
Safety of Devascularization Procedure
Hysterectomy
Selective Arterial Embolization (Fig. 14)
Acknowledgement
43:
Postpartum Collapse
CAUSES OF SUDDEN COLLAPSE IN PREGNANCY AND POSTPARTUM (FIG. 1)1
5 H's
4 T's
Abnormalities of Third Stage (Causes of Sudden Postpartum Collapse)2
POSTPARTUM COLLAPSE: PRINCIPLES OF MANAGEMENT (FLOW CHART 1)
Prevention: “An Ounce of Prevention is Better than a Pound of cure”
Resuscitative Measures
Always Maintain the Following
AMNIOTIC FLUID EMBOLISM (AFE)2,3
Medical Care
ACUTE INVERSION OF UTERUS2,7
Types
Clinical Features (Flow chart 2)
Signs
Management Acute/Subacute Cases
PULMONARY THROMBOEMBOLISM8
Clinical Presentation8
Diagnosis
Management
SEPTIC SHOCK
Predisposing Factors
Management
Principles of Management
Regional Anesthesia/Drug toxicity2,9
Diagnosis
Management
PERIPARTUM CARDIOMYOPATHY10,11
Risk Factors (Fig. 3)
Diagnostic Criteria by Demkasis and Rahimtoola
Clinical Features
Management
Investigations
Treatment
CONCLUSION
44:
Emergency Cesarean Section
INTRODUCTION AND GENERAL CONSIDERATION
DEFINITION OF ELECTIVE AND EMERGENCY CESAREAN SECTION
Elective Cesarean Section
Emergency Cesarean Section
CLASSIFICATION/CATEGORIZING THE EMERGENCY CESAREAN SECTION
INCIDENCE OF CESAREAN SECTION WITH REFERENCE TO EMERGENCY CESAREAN SECTION
PRESENTATION IN EMERGENCY CESAREAN SECTION
RISKS AND BENEFITS OF ELECTIVE VS EMERGENCY CESAREAN SECTION
PROTOCOL FOR SAFE OBSTETRICS AND SAFE EMERGENCY CESAREAN SECTION
CONCLUSION
SECTION 5: NEWBORN CARE
45:
Care of Newborn
INTRODUCTION
WHAT PREPARATIONS SHOULD BE DONE FOR THE CARE OF THE NEWLY BORN?
WHAT ARE ISSUES OF CONCERN IN THE FIRST FEW HOURS OF BIRTH IN NORMAL NEWBORN?
WHAT ARE ISSUES OF CONCERN DURING INITIAL FEW DAYS OF LIFE?
Physical Examination
Screening
Routine Assessments
Weight Change Pattern in Term Baby
Early Identification of Disease (Danger Signs)
WHEN SHOULD NORMAL NEWBORN BE DISCHARGED FROM HOSPITAL?
Home Care
Follow-up
SUMMARY OF RECOMMENDATIONS
46:
Preterm Baby— An Obstetrician's Approach
INTRODUCTION
ETIOLOGY
RISK FACTORS
DIAGNOSIS
PREDICTION OF PRETERM DELIVERY
FETAL FIBRONECTIN
MEASURES TO IMPROVE PERINATAL OUTCOMES
VAGINAL DELIVERY OR CESAREAN?
NEONATAL RESUSCITATION IN PRETERM
KEY MESSAGE
47:
Meconium Stained Baby
DEFINITION
EPIDEMIOLOGY/INCIDENCE
PATHOPHYSIOLOGY
Composition of Meconium
Causes of MSAF
Mechanism of Injury
RISK FACTORS
CLINICAL PRESENTATION OF MAS
SEVERITY OF MAS
DIAGNOSIS
PREVENTION
MANAGEMENT
Management of Infants Delivered through Meconium Stained Fluid
Management of Meconium Aspiration Syndrome
General Care
Oxygen Therapy
Assisted/Mechanical Ventilation
Medications/Nitric Oxide/ECMO
COMPLICATIONS AND PROGNOSIS
48:
Fresh Stillbirth: Evaluation and Risk Management
49:
Macerated Stillbirth/IUFD
INTRODUCTION
DIAGNOSING FETAL DEATH
BREAKING THE BAD NEWS3
INVESTIGATIONS TO BE DONE PRIOR TO BIRTH2.3.4
INVESTIGATIONS TO BE DONE POST-DELIVERY2–4
BIRTH AND INDUCTION OF LABOR
SUBSEQUENT PREGNANCY CARE
50:
Early Neonatal Loss
INTRODUCTION
DEFINITIONS
Neonatal Mortality
India's Performance
Neonatal Mortality Rate (NMR)
Perinatal Mortality
Perinatal Mortality Rate
Stillbirth
Infant Mortality
CAUSES7 (FIG. 1 AND TABLE 2)
OTHER CAUSES OF NEONATAL DEATH
NEONATAL RESUSCITATION (FIG. 2)
Adult versus Newborn Resuscitation (Flow chart 1)
FOUR MAJOR INTERVENTIONS TO REDUCE NEONATAL MORTALITY8
First Intervention
Second Intervention
Third Intervention
Fourth Intervention
MANAGEMENT AND PREVENTION OF NEONATAL MORTALITY
Care of the Baby
Immediate Care
Priority Areas to Improve Newborn Health
Before and During Pregnancy
During Pregnancy
During and Soon after Delivery
During the First Month of Life
APGAR SCORE
Interpretation
51:
Lactation Management in Normal Birth
INTRODUCTION
ROLE OF MATERNITY SERVICES: TEN STEPS TO SUCCESSFUL BREASTFEEDING
LACTATION MANAGEMENT IN NORMAL BIRTH
In Adolescence/Prepregnancy state
In the Antenatal Period
In the Birthing Suite (Labor Room)
In the Wards
ISSUES
Less Milk and the Fear of Hypoglycemia
Supplementary Feeds
The Baby Cries
How do you know that the Breastmilk is Adequate?
Common Problems: Cracked Nipple and Engorged Breast
Advice at Discharge
52:
Breastfeeding Management at Cesarean Section
INTRODUCTION
INITIATION OF BREASTFEEDING AFTER CD
Myths/Questions/Wrong Ideas and Practices
Different Initiation Scenarios
Scientific Information
Comments—Suggestions for Action
BREASTFEEDING POSITIONS AFTER CD
Myths/Questions/Wrong Ideas and Practices
Scientific Information
Comments—Suggestions for Action
SUPPLEMENTATION IN BABIES DELIVERED BY CD
Myths/Questions/Wrong Ideas and Practices
Scientific Information
Comments—Suggestions for Action
IMPACT OF CD ANESTHESIA ON BREASTFEEDING
Myths/Questions/Wrong Ideas and Practices
Scientific Information
Comments—Suggestions for Action
ANALGESIA AND BREASTFEEDING
Questions, Myths, Wrong Ideas and Practices
Scientific Information
Oral Medications
Epidural/Spinal Medications
Comments—Suggestions for Action
BEDDING-IN/ROOMING-IN AFTER CD
Myths/Questions/Wrong Ideas and Practices
Scientific Information
Comments—Suggestions for Action
INDICATION FOR CD AND BREASTFEEDING
Myths/Questions/Wrong Ideas and Practices
Scientific Information
Comments—Suggestions for Action
CD RATE AND IMPACT ON BREASTFEEDING
Myths/Questions/Wrong Ideas and Practices
Scientific Information
Comments—Suggestions for Action
SUMMARY
SECTION 6: RECENT ADVANCES AND SPECIAL SITUATIONS
53:
Informed Consent
INTRODUCTION
THE LEGAL BASIS OF CONSENT
CAPACITY AND INFORMATION WHILE SEEKING CONSENT
INDIAN LAW ON CONSENT
EMERGENCY SITUATION AND CONSENT
54:
WHO Checklists
INTRODUCTION
WHO CHECKLIST
Pre-requisites
INDEX
TOC
Index
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