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 _I l_i z Textbook of
OBSTETRICS
sanket munde is best friend of bharat huse
Including Perinatology and Contraception
VIDEO LIST FOR THE KERNEL
9.
Lecture Series Case Presentations
1. Informed Consent Dr Roshini P 2. FOGSI Dr Roshini P
Obstetrics History Taking and Physical Dr Roshini P Examination
3.
Bony Pelvis and Fetal Skull Dr Rajiv Kumar Saxena
4.
Pelvic Floor and its Clinical Significance Dr Rajiv Kumar Saxena
5.
6. WHO Labor Care Guide Dr Roshini P
7. Induction and Augmentation of Labor Dr Roshini P from Old to New
8. Artificial Rupture of Membranes (ARM) Dr Roshini P
1. Anemia Complicating Pregnancy Dr Roshini P, Dr Rajiv Kumar Saxena
2. Pregnancy with History of Prior Dr Roshini P, Dr Rajiv Cesarean Delivery Kumar Saxena
Multiple Pregnancy Dr Roshini P, Dr Rajiv Kumar Saxena
3.
Rh Negative Pregnancy Dr Roshini P, Dr Rajiv Kumar Saxena
4.
5. Pre-eclampsia and Eclampsia Dr Roshini P, Dr Rajiv Kumar Saxena
6. Diabetes in Pregnancy Dr Roshini P, Dr Rajiv Kumar Saxena
Animation Videos
Mechanism of Normal Labor 10. Mal positions
11. Mal presentations
12. Cardiotocographic Assessment of Fetal Wellbeing
13. Assisted Vaginal Breech Delivery 14. External Cephalic Version
15. Episiotomy-Selective Use Justified 16. Vacuum Extraction (OVD)
17. Operative Vaginal Delivery: Forcep Delivery
18. Postpartum Hemorrhage
19. Drugs and Suture Material in Obstetrics
Dr Roshini P Dr Roshini P Dr Roshini P Dr Roshini P
Dr Roshini P
Dr Rajiv Kumar Saxena
Dr Roshini P
Dr Rajiv Kumar Saxena
Dr Rajiv Kumar Saxena
Dr Roshini P
Dr Roshini P
1. Fertilization, Implantation and Embryogenesis 2. Artificial Rupture of Membranes (ARM)
3. Normal Labor Episiotomy
4.
5. Third Stage of Labor
6. External Cephalic Version Breech Delivery
7.
8. Vacuum Extraction Forceps Delivery
9.
10. Cesarean Section
11. Postpartum Hemorrhage
Presentations
Analgesia and Anesthesia in Labor 2. Urinary Catheterization and its Care
1.
3. Surgical Site Infection Care
20. Instruments in Obstetrics
21. Cesarean Delivery-the Past and Present
22. Neonatal Resuscitation Protocol
23. Female Catheterization
Dr Roshini P
Dr Rajiv Kumar Saxena
Dr Roshini P
Dr Roshini P
Important Topics
1. Quick Revision Topics for Viva Voce and MCQ Based on Entrance Examinations (with PDF)
2. Self-Assessment Questions for Obstetric Long Case Discussions (PDF)
_I 1 _I z Textbook of
OBSTETRICS
Including Perinatology and Contraception
Tenth Edition
DCDUTTA MBBS, DGO, MO (CAL)
Professor and Head, Department of Obstetrics and Gynecology Nilratan Sircar Medical College and Hospital, Kolkata, India
Edited by HIALAL KONAR
(HONS; GOLD MEDALIST) MBBS (CAL), MD (PGI), DNB
MNAMS, FACS (USA), FRCOG (LONDON)
Professor and Head, Department of Obstetrics and Gynecology KPC Medical College and Hospital, Kolkata, West Bengal, India
Formerly, Professor and Head, Department of Obstetrics and Gynecology
Agartala Government Medical College and Hospital; Tripura, Midnapore Medical College and Hospital, West Bengal University of Health Sciences, Kolkata, West Bengal, India Rotation Registrar in Obstetrics, Gynecology and Oncology Northern and Yorkshire Region, Newcastle-upon-Tyne, UK
Examiner: National-MBBS, DGO, MD and PhD of different Indian Universities National Board of Examination, New Delhi, India
International-Membership of the Royal College of Obstetricians and Gynecologists, London (MRCOG) and Royal College of Physicias of Ireland (MRCPI)
Vice-President: FOGSI; Indian Society of Perinatology and Reproductive Biology (ISOPARB)
Recipient, "Pride of FOGSI Award" and "FOGS! Achiever Award': for exemplary works towards upliftment of Women's Health in India FOGSI Representative to Asia Oceania Federation of Obstetricians and Gynecologists (AOFOG) Chairman, Indian College of Obstetricians and Gynecologists (ICOG-2013)
JAYPEE BROTHERS MEDICAL PUBLISHERS The Health Sciences Publisher
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Landline: +91-11-23272143, +91-11-23272703 +91-11-23282021, +91-11-23245672
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New Delhi 110 002, India Phone: +91-11-43574357 Fax: +91-11-43574314
Email: [email protected]
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© 2023, Copyright reserved by Mrs Madhusri Konar
Overseas Ofice J.P. Medical Ltd
83 Victoria Street, London SWl H 0HW (UK)
Phone: +44 20 3170 8910 Fax: +44 (0)20 3008 6180 Email: [email protected]
The views and opinions expressed in this book are solely those of the original contributor(s)/author(s) and do not necessarily represent those of editor(s) and publisher of the book.
All rights reserved. No part of this publication including videos, graphics, photographs, designs, flowcharts, boxes, tables, QR codes and its contents may be reproduced, stored or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of the publishers and author.
All brand names and product names used in this book are trade names, service marks, tradema!ks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book.
Medical knowledge and practice change constantly. This book is designed to provide accurate, authoritative information about the subject matter in question. However, readers are advised to check the most current information available on procedures included and check information from the manufacturer of each product to be administered, to verify the recommended dose, formula, method and duration of administration, adverse effects and contraindications. It is the responsibility of the practitioner to take all appropriate safety precautions. Neither the publisher nor the author(s)/editor(s) assume any liability for any injury and/or damage to persons or property arising from or related to use of material in this book.
This book is sold on the understanding that the publisher is not engaged in providing professional medical services. If such advice or services are required, the services of a competent medical professional should be sought.
Every effort has been made where necessary to contact holders of copyright to obtain permission to reproduce copyright material. If any have been inadvertently overlooked, the publisher will be pleased to make the necessary arrangements at the first opportunity.
Inquiries for bulk sales may be solicited at: [email protected] extbook of Obstetrics
Ninth Edition: 2018 Tenth Edition: 2023 ISBN: 978-93-5465-902-7
Printed at: Sam rat Offset Pvt. Ltd.
Dedicated to
The students of obstetrics­ past and present
Contributors
BB Hore MD
Former Professor and Head Calcutta Medical College, Kolkata Consultant Anesthetist
Kolkata, West Bengal, India
Santanu Bag FRCPCH (UK) CCT Assistant Professor Consultant Neonatologist
Rama Krishna Mission Seva Pratisthan
and Vivekananda Institute of Medical Sciences Kolkata, West Bengal, India
Sir Sabaratnam Arulkumaran PhD DSc FRCOG FRCS Professor Emeritus
St George's University, London
Past President-FIGG, BMA and RCOG
Preface to the Tenth Edition
With great pleasure we release the tenth edition of Dutta's Textbook of Obstetrics. Obstetric care is evolving fast with the progress in science and technology. The tenth edition has come up much earlier to ensure the updated knowledge and practice for the students and practitioners.
It is more than forty years that Prof. DC Dutta, the visionary leader of education recognised the need for such a book primarily intended for the medical and nursing students, residents and the practising obstetricians.
The changes in the present edition are significant and are in accordance with the current guidelines of National Medical Commission (NMC). This edition has been updated as per the CBME curriculum. It carries the extensive use of imaging studies as it is the need of the day. The chapter outlines, good number of tables, boxes are incorporated for easy understanding and reproduction.
We are indebted to Sir, Professor Sabratnam Arulkumaran, for revising the chapters: Normal Labor (Ch. 13) and Intrapartum Fetal Monitoring (Ch. 39). We are grateful to Dr S Bag, FRCPCH (UK), CCT, Assistant Professor, Department of Neonatology, RKMSP and Vivekananda Institute of Medical Sciences (VIMS), Kolkata, for updating the chapters on perinatal care (Ch. 31, 32, 33). We sincerely acknowledge Prof. K Oswal and Dr K Mukherjee, Sonologists, for their generous support. We are indebted to Prof. BB Hore, for the revising the Ch. 34 (Analgesia and Anesthesia in Obstetrics) as before. My sincere thanks are to Dr Chandrachur Konar, Dr Roshni P and Dr Lisley Konar, for their all round support for this edition.
The uniqueness of this text lies in its presentation, which is simple, lucid and unambiguous. Summary tables, key points, algorithm and the flowcharts are for quick revision before exams. Uniformity of information in all the chapters is a special value. Contemporary guidelines of different professional and academic organizations, e.g., RCOG, ACOG, ICOG, WHO, FIGO, NICE, CDC, ESHRE, ASRM, FOGSI are incorporated. List of most frequently used abbreviations have been provided for easy navigation. This edition, in its fully colored format is profusely illustrated with more than 790 line drawings, sketches and photographs.
I had the opportunity of visiting many medical institutions in this country and abroad. The feedback that I have received form the teachers and students are invaluable. Many of the suggestions have been addressed in this edition. The editor always welcomes the views of the students and the teachers through online access to e-mail: h.kondr@gmail. com and websites: hiralalkonar.com and dcdutta.com. Regarding the video section, interested readers keen to know more could reach out at: [email protected].
Dutta's Textbook of Obstetrics has a long-standing association with its sister books: Textbook of Gynecology (8th Edition, 2020), Clinics in Obstetrics (1st Edition, 2022), Clinics in Gynecology (1st Edition, 2022) and Bedside Clinics and Viva Voice (7th Edition, 2020).
The online version of this comprehensive book has been prepared by a very young and talented team members (Dr Chandrachur Konar, Dr Roshini P and Prof. Rajiv Kumar Saxena). Online version is_ extensively available. It has the flexibility of using the text content and video materials for clinical and practical purposes. Its content will be revised and updated annually as necessary.
I do hope that this comprehensive textbook will continue to be of immense educational resource to the readers as ever. I am grateful to those who have taught me, most of all, the patients and my beloved students.
According to the author's desire, this book is dedicated to the students of obstetrics: past and present, who strive relentlessly to improve maternal and newborn health care wherever they work.
J{ira[a[ l(onar
P-13, New CIT Road Kolkata-700014 India
Preface to the First Edition
Over the years, there was an absolute dearth of a single comprehensive textbook of obstetrics, worth to be prescribed to the students. Moreover, of the textbooks currently available, most have been written with an orientation for the developed countries.
Being constantly insisted and hard-pressed by my beloved students, I ultimately decided to write a compact, comprehensive and practically oriented textbook of obstetrics. It is an attempt to encourage the students to learn obstetrics in a comparatively easy way. The aim was to emphasize the simplicities rather than complexities of knowledge. The book is written in a clear and concise language and in author's own style, which holds the reader's interest. Controversies are avoided and the management of the obstetrical problems is being highlighted with the facilities available to most of the Third World countries. Extensive illustrations and flow charts (schemes) have been used as and when needed to add lucidity and clarity to the subject and to emphasize the practical nature of the book.
Although the book has been written primarily for the undergraduates, it should also prove to be useful to nurses (midwives), those aspiring for diploma and postgraduate degrees in obstetrics, and also to the practicing obstetricians. I, however, do not consider this book to be an ideal one but a humble attempt has been made to remove the bottlenecks, as far as possible, of the books available to the students at present.
Acknowledgments: Very little of what is worthwhile in this book could not have been brought to publication without the generous cooperation, advice and assistance of many of my colleagues, seniors and juniors.
Dr BN Chakravarty, MBBS, DGO, MO (CAL), FRCOG (Eng), Prof., Department of Obstetrics and Gynecology, Nilratan Sircar Medical College, Kolkata; Dr KM Gun, MBBS, DGO, MO (CAL), FRCOG (Eng), FRCS (Edin), FACS, Prof., Department of Obstetrics and Gynecology, Medical College, Kolkata; Dr Santosh Kr Paul, MBBS, DGO, MO (CAL), Reader, Department of Obstetrics and Gynecology, Nilratan Sircar Medical College, Kolkata; Dr B Hore, MBBS, DA, MS (CAL), Prof. and Head of the Department of Anesthesiology, North Bengal Medical College, Siliguri; Dr BC Lahari, MBBS, DGO, MO (CAL), FRCS (Edin), FRCOG (Eng), FACS (USA), FAMS (Ind), Prof., Department of Obstetrics and Gynecology, Medical College, Kolkata; Dr NN Roy Chowdhury, MBBS, DGO, MO (CAL), PhD, FRCS, FRCOG, FACS, FAMS, Prof., Department of Obstetrics and Gynecology, Medical College, Kolkata.
I have much pleasure in expressing my cordial appreciation to the house-surgeons, internees and students of Nilratan Sircar Medical College, Kolkata, for all the help they have rendered in preparation of the final drafts of the manuscripts, checking the proofs, and in compiling the Index. Without their constant encouragement and active assistance, this book could never have been published.
In preparing a textbook like this, I have utilized the knowledge of a number of stalwarts in my profession and consulted many books and publications. I wish to express my appreciation and gratitude to all of them, including the related authors and publishers.
As a teacher, I have learnt a lot from the students and, more so, while writing this book and, as such, I could not think of dedicating the book to anyone else but the students of obstetrics, for which I express my gratitude.
Mahalaya f)C f)utta 8th September, 1983
P-13, New CIT Road Kolkata-700014 India
Acknowledgments
The job of editing such a comprehensive text is stupendous and it could never be completed without the help and advice of many experts in the field. I have consulted many of my esteemed colleagues in the profession in this country and abroad, multitude of eminent authors, many current evidence-based studies, guidelines and recommendations. I do gratefully attribute my legacy to all the teachers, related authors and the publishers.
At the outset, I am indebted wholeheartedly for the support provided by Prof. BB Hore, Consultant Anesthetist, Sir Sabaratnam Arulkumaran, Emeritus Professor, and Dr Santanu Bag, Assistant Professor and Consultant Neonatologist, for their contributions of the respective topics. I am extremely grateful to Mrs Madhusri Konar, MA, BEd, for all her insightful secretarial accomplishments in support of the book.
I gratefully thank Shri Jitendar P Vij (Group Chairman), Mr Ankit Vij (Managing Director), Mr MS Mani (Group President), Dr Madhu Choudhary (Director-Educational Publishing), Ms Pooja Bhandari (Production Head), Ms Sunita Katia (Executive Assistant to Group Chairman and Publishing Manager), for their all-round support as and when needed. I also acknowledge the help of Dr Aditya Tayal (Team Leader-Development Editor), Mr Rajesh Sharma (Production Coordinator), Ms Seema Dogra (Cover Visualizer), Mr Laxmidhar Padhiary (Quality Controller), Mr Ajeet Rathor (Typesetter), Mr Akshay Thakur (Typesetter), Mr Manoj Pahuja (Senior Graphic Designer), and wish to thank all others of M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India, who worked for this project.
International Reviewers
I am especially indebted to all the international reviewers: Sir Sabaratnam Arulkumaran, PhD, DSc, FRCOG, FRCS, Prof. Emeritus, St George's University of London, Past President-FIGG, BMA and RCOG; Dr Michael P O'Connel, Royal College of Physicians, Dublin; Prof. Colm O'Herlihy, National Maternity Hospital, Dublin; Prof. Farhana Dewan; Prof. Kohinoor Begum, Bangladesh; Prof. Rokeya Begum, Bangladesh; Prof. Rowshan Ara Begum; Prof. Sabera Khatun, Bangladesh; Prof. S Nurjahan Bhuiyan, Bangladesh; Prof. PR Pant, Tribhuvan University Teaching Hospital (TUTH), Nepal.
National Reviewers
I sincerely acknowledge the following teachers across this vast country for their valuable suggestions. Their comments and guidance have helped me enormously to shape this new edition. I hope that I have listed all of those who have contributed and apologize if any name has been left out inadvertently.
My sincere thanks are due to Prof. Gita B Banerjee, CRSS, Kolkata; Prof. Picklu Choudhury, RPH MCH, West Bengal; Prof. PK Biswas, CNMCH, Kolkata; Prof. Narayan Jana, CRSS, Kolkata, Prof. Habibullah, MGMC, Puducherry; Prof. Ashok Kumar, Delhi; Prof. Pranay Nath, Prof. Gita Guin, NSCBMC, Jabalpur; Prof. Tusar Kar, Cuttack; Prof. Bharati Mishra, Brahmapur, Odisha; Prof. Ava Rani Sinha, Mujaffarpur; Prof. Vinita Sharma, PGI, Chandigarh; Prof. Kiran Pandey, GSVMMCH, Kanpur; Prof. Sowjanya Kumari, Tirupati; Prof. Suyajna, VIMS, Bellary; Prof. Sampatkumari, Tamil Nadu; Prof. Muralidhar Pai, KMC, Manipal; Prof. Devinder, AFMC, New Delhi; Prof. Himadri Bal, DY Patil MCH, Pune; Prof. M Sarkar, EMCH, West Bengal; Prof. H Rahman, Gangtok; Prof. Deepa Masand, NIMS, Jaipur; Prof. Ajith, Kannur; Prof. Pratap Kumar, KMC, Manipal; Prof. Nilesh Dalal, MGMC, Indore; Prof. SS Gulati, SMC, Noida; Prof. Jaya Chaturvedi, AIIMS, Rishikesh; Dr Sujatha, AMC, Visakhapatnam; Prof. Savita C, BMC, Karnataka; Prof. RC Antaratan, Hubli; Prof.
Umdi, Belagavi, IMS; Prof. Dharma Vijay MN, MVJMC&RH; Prof. Anju Agarwal, KGMC, Lucknow; Prof. Wani Aditya,
BRD Medical College, Gorakhpur; Prof. MD Pant, KMC, Manipal; Prof. Pushpalata, AIIMS, Bhopal; Prof. Prativa Singh, AIIMS, Jodhpur; Prof. Nirja Bhatia, AIIMS, New Delhi; Prof. Beena Kumari R, GMC, Kattayam; Prof. Nirmala, GHC, Thiruvananthapuram; Prof. Sarina Gilvaz, JMMCH; Prof. Radhamani K, IMS, Amrita Institute of Medical Sciences; Prof. T Padmabvathi, Andhra MCH; Prof. Pradeep S, PESIMSR, Kuppam; Prof. S Vijaya, Madras MCH; Prof. K Kalaivani, Stanley MCH; Prof. Krishnapriya Banerjee, SMSMCH, Jaipur; Prof. Parmeet Kaur, GMC, Patiala; Prof. Lajya Devi Goyel, AIIMS, Bhatinda; Prof. Amrit Pal Kaur, GMC, Amritsar; Prof. Seema Grover Bhatty, GGSMCH, Faridkot; Prof. Ashoke Anand, Grant MC, Mumbai; Prof. NM Mayadeo, KEM Hospital; Prof. JK Deshmukh, GMC, Nagpur; Prof. Brig Aruna Menon, AFMC, Pune; Prof. Hemant Deshpande, DY Patil MCH, Pune; Prof. T Panchanadikar, BVPMC, Pune; Prof. AV Mehta, BJMCH,
Ahmedabad; Prof. Gokhale, GMC, Baroda; Prof. Haresh Dashi, GCS MCH, Ahmedabad; Emeritus Prof. Dr Habibullah,
MGMCH, Puducherry; Prof. Seetesh Ghose, Dean, MGM MCH; Prof. Gauri, JIPMER; Prof. Lata, JIPMER, Puducherry,
!I Acknowledgments
Prof. Manidip Pal, Kalyani KMC; Prof. Sarita Agarwal, Raipur; Prof. Tripti Nagaria, JNMCH, Raipur; Prof. Uma Pandey, BHU; Prof. BM Rakshit, MCH, Kolkata; AGMC, Shimla; Prof. Pranay Phukan, Dibrugarh; Prof. J Ray, GMCH, Agartala; Prof. Debutta, RG Kar MCH, Kolkata; Prof. T Maity; Prof. A Phadikar, NRSRCH; Prof. Anuradha Chatterjee, NBMCH; Dr Pallab Mistri, Associate Professor, CMC, Kolkata; Dr Arindam Halda1 Associate Professor, Raiganj MCH; Prof. S Biswas, IGMER, Kolkata; Prof. Malbika Mishra, JIMS, Budge Budge; Prof. S Barik, Haldia Medical College; Prof. Sasavati Sanyal Choudhary; Prof. Alakananda, GMCH, Guwahati; Prof. P Das, Guwahati MCH; Prof. Kavita Mandrella Bhatti, CMC, Ludhiana; Prof. Aparajita S D'Souza, ESIC MCH, Hyderabad; Prof. BS Meena, SMSMCH, Jaipur; Prof. Seema Hakim, AMU, Aligarh; Dr AK
Bhattacharya, Associate Profess01 Jorhat Medical College; Prof. HK Sharma, Jorhat MCH; Prof. Panchanan Das, GMCH,
Guwahati; Lt Col. Prof. Indrani Mukopopadhyay, AFMC; Dr Saumen Das Poddar, AFMC, and Col. Bidhan Ray, AFMC.
I sincerely thank Prof. Rajiv Saxena, Dr Chandrachur Konar, Dr (Mrs) Roshini P, and Dr Lisley Konar, for their untiring effort for the all-round support to this tenth edition of the book.
I express my sincere thanks to all the teachers and students of different medical institutes, midwifery institutes, and nursing colleges in India and abroad for their valued suggestions, new ideas and contribution of photographs. Their inputs have been invaluable and much appreciated.
Last but not least, I am grateful to all who have taught me, most of all the patients and my beloved students.
The editor always welcomes the views of the students and the teachers through online access to e-mail: h.kondr@ gmail.com; [email protected]; and, websites: hiralalkonar.com and dcdutta.com.
J{iraCa[ l(onar P-13, New CIT Road
Kolkata-700014 India
1).(J.f),.: 1932UL oc
List of Video Contributors
Rajiv Kumar Saxena MBBS, MD Professor and Head
Department of Obstetrics and Gynecology
The Oxford Medical College, Hospital and Research Centre
Bengaluru, Karnataka, India
Roshini p MBBS MS DNB Assistant Professor
Department of Obstetrics and Gynecology ESIC and PGIMSR
Bengaluru, Karnataka, India
Contents
IJ 'Anatomy of Female Reproductive Organs
■ External Genitalia 1; • Mons Veneris 2; • Labia Majora 2; • Labia Minora 2; • Clitoris 2; • Vestibule 2; • Perineum 3; ■ Internal Genitalia 3; • Vagina 3; • Uterus 4; • FallopianTube 6; • Ovary 7; • Muscles and Fascia in Relation to the Pelvic Organs 9; • Pelvic Floor 9; • Perineum 1 O; • Pelvic Fascia 11; ■ Pelvic
CellularTissue 11; ■ Female Urethra 12; ■ Urinary Bladder 12; ■ Pelvic Ureter 12; ■ Breasts 13
II Fu"! amentaJs of Reproduction 16
■ Gametogenesis 16; • Oogenesis 16; • Spermatogenesis 18; ■ Ovulation 18; ■ Fertilization 19;
• Morula 20; • Blastocyst 20; ■ Implantation 21; • Trophoblast 21; ■ Decidua 22; ■ Chorion and
Chorionic Villi 23; ■ Development of Inner Cell Mass 23
11 lPl centa and Fetal Membranes 26
■ Placenta 26; • Development 26; • Placenta at Term 27; • Structures 27; ■ Placental Circulation 29;
■ Placental Aging 31; ■ Placental Function 32; ■ Fetal Membranes 34; ■ Amniotic Cavity and Amnion 34;
■ Amniotic Fluid 34; ■ Umbilical Cord 36
II The Fetus 38
■ Fetal Physiology 39; ■ Fetal Circulation 40; • Changes in the Fetal Circulation at Birth 41 II l hysiological Changes During regnancy
■ Genital Organs 43; • Uterus 43; ■ Breasts 46; ■ Cutaneous Changes 46; ■ Weight Gain 47; ■ Body Water Metabolism 47; ■ Hematological Changes 48; ■ Cardiovascular System 49; ■ Metabolic Changes 50;
■ Systemic Changes 51
II E.1docri ?Logy i R , tion to Repro udion 55
■ Maturation of Graafian Follicles and Ovulation 55; ■ Maintenance of Corpus Luteum after Fertilization 55; ■ Placental Endocrinology 55; • Hormones of Placenta 55; • Protein Hormones 55; • Steroidal Hormones 57; • Diagnostic Value of Placental Hormones 58; ■ Changes in Endocrine Glands During Pregnancy 58; • Pituitary Gland 58; • Thyroid Gland 58; • Adrenal Cortex 59; • Parathyroid
Gland 59; • Pancreas 59; ■ Hormonal Influences Necessary for Maintenance of Lactation 59
II I Diagnosis of regnancy 61
■ FirstTrimester (First 12 Weeks) 61; ■ Second Trimester (13-28 Weeks) 63; ■ LastTrimester (29-40
Weeks) 65; ■ Differential Diagnosis of Pregnancy 66; ■ Chronological Appearance of Specific Symptoms and Signs of Pregnancy 66; ■ Signs of Previous Childbirth 66; ■ Estimation of Gestational Age and Prediction of
Expected Date of Delivery 67; ■ Estimation of Fetal Weight 67
II The Fetus-in-Utero 69
■ Causes of Preponderance of Longitudinal Lie and Cephalic Presentation 71; ■ Methods of Obstetrical
Examination 71
ll rFetal Skull and Maternal Pelvis 76
■ Fetal Skull 76; ■ Pelvis 79; • False Pelvis 79; • True Pelvis 80; • Inlet 80; • Cavity 82; • Outlet 82; • Midpelvis 83; • Physiological Enlargement of Pelvis during Pregnancy and Labor 85
al IComnteAnntstenatal Care, Preconceptional Counseling and Care ___ 86 ■ Procedure at the First Visit 86; • History Taking 86; • Examination 88; ■ Procedure at the Subsequent
Visits 90; ■ Antenatal Advice 90; ■ Minor Ailments in Pregnancy 92; ■ Values of Antenatal Care 93; ■ Preconceptional Counseling and Care 94
Antenatal Assessment of Fetal Wellbeing 95
■ Clinical Evaluation of Fetal Wellbeing at Antenatal Clinic 95; • First Visit 95; • Subsequent Visits 95;
• Special Investigations 96; • Early Pregnancy 96; ■ Antepartum Fetal Surveillance (Late Pregnancy) 96; ■ Other Investigations in Late Pregnancy 99
Prenatal Genetic Counseling, Screening and Diagnosis 102
■ Prenatal Genetic Screening 102; • Prenatal Diagnosis 104; ■ Invasive Procedures for Prenatal Diagnosis 104; • Chorionic Villus Sampling 104; • Amniocentesis 105; • Cordocentesis or Percutaneous Umbilical Blood Sampling 105; ■ Noninvasive Method of Prenatal Testing from Maternal Plasma/Blood 106; • Fetal DNA 106
Normal Labor: lntrapartum Care for a Positive Child Birth Experience (WHO) 108
■ Labor 108; • Onset 108; • Contractile System of the Myometrium 109; ■ Physiology of Normal Labor 111; ■ Events in First Stage of Labor 113; ■ Events in Second Stage of Labor 115; ■ Events in Third Stage of Labor 116; ■ Mechanism of Normal Labor 117; ■ Anatomy of Labor 120; ■ Clinical Course of First Stage of Labor 121;
■ Clinical Course of Second Stage of Labor 124; ■ Clinical Course ofThird Stage of Labor 125; • Place of Delivery 126; ■ Management of Normal Labor 126; ■ Management of First Stage of Labor 127; ■ Management
of Second Stage of Labor 129; • Immediate Care of the Newborn 131; ■ Management ofThird Stage of Labor 132;
• Active Management ofThird Stage of Labor (AMTSL) 132; • Labor Care Guide (WHO) 136
IJ Normal Puerperium 139
■ Involution of the Uterus 139; ■ Involution of Other Pelvic Structures 140; • Lochia 141; ■ General Physiological Changes 141; ■ Lactation 142; • Physiology of Lactation 143; ■ Management of Normal Puerperium 144; ■ Management of Ailments 145; ■ Postnatal Care 147
Nausea and Vomiting in Pregnancy
■ Vomiting in Pregnancy 149; ■ Hyperemesis Gravidarum 149;
m
Hemorrhage in Early Pregnancy
149
• Clinical Course 150; • Management 151
153
■ Spontaneous Abortion (Miscarriage) 153; ■ Threatened Miscarriage 155; ■ Inevitable Miscarriage 156; ■ Complete Miscarriage 156; ■ Incomplete Miscarriage 157; ■ Missed Miscarriage 157; ■ Septic Abortion 158; • Management 159; ■ Recurrent Miscarriage 160; ■ Cervical Incompetence 162;
■ Induction of Abortion 166; ■ Medical Termination of Pregnancy (MTP) 166; • Methods ofTermination of Pregnancy 166; • Recommendations 167; • First Trimester Termination of Pregnancy 167; • Midtrimester Termination of Pregnancy 168; ■ Ectopic Pregnancy 170; • Tubal Pregnancy 170; • Acute Ectopic Pregnancy 172; • Unruptured Tubal Ectopic 172; • Diagnosis of Ectopic Pregnancy 173; ■ Management of Ectopic Pregnancy 174; • Interstitial 178; • Abdominal 178; • Ovarian 179; • Cornual 179;
• Cervical 180; • Pregnancy of Unknown Location 180; • Cesarean Scar Pregnancy 180; • Heterotopic Pregnancy 181; ■ Gestational Trophoblastic Diseases (GTD) 182; • Hydatidiform Mole 182; • Partial or Incomplete Mole 187; • Placental Site Trophoblastic Tumor (PSTT) 188; • Persistent Gestational Trophoblastic Disease 188
Multiple Pregnancy, Amniotic Fluid Disorders, Abnormalities of Placenta and Cord 190
■ Twins 190; • Diagnosis 192; • Complications 194; • Prognosis 196; • Complications of Monochorionic Twins 196; ■ Antenatal Management 197; ■ Management during Labor 198; ■ Triplets, Quadruplets,
etc. 200; ■ Amniotic Fluid Disorders 202; • Polyhydramnios 202; • Etiology 202; • Complications 203;
■ Management of Hydramnios 204; • Acute Polyhydramnios 205; • Oligohydramnios 205; ■ Abnormalities of Placenta and Cord 206; • Placental Abnormalities 206; • Cord Abnormalities 208
Contents - ....
lJ 1:iypertensive Disorders inwPr nancy .. 209 ■ Pre-eclampsia (PE) 209; • Diagnostic Criteria 210; • Etiopathogenesis 210; • Pathophysiology 211;
• Clinical Types 213; and Prevention 215;
• Clinical Features 213; • Complications 215; • Screening Tests for Prediction • Prophylactic Measures for Prevention 216; • Management of Gestational
Hypertension and Pre-eclampsia 217; ■ Acute Fulminant Pre-eclampsia 220; ■ Eclampsia 221; • Clinical Features 222; • Prognosis 222; • Management 222; ■ Chronic Hypertension in Pregnancy 226;
■ Essential Hypertension in Pregnancy 226; ■ Chronic Renal Diseases in Pregnancy 227; ■ Pregnancy after Renal Transplant 228
m
Antepartum Hemorrhage 230
■ Placenta Previa 230; • Etiology 230; • Clinical Features 232; • Differential Diagnosis 233;
• Complications 233; • Prognosis 235; • Management 235; ■ Practical Guide for Cesarean Delivery 238; ■ Practical Approach to Lower Segment CD for Placenta Previa 238; ■ Practical Guide to Lower Segment Approach for Placenta Previa Accreta 238; ■ Abruptio Placentae 239; • Clinical Features 241;
• Management 241; • Treatment in the Hospital 242; • Indeterminate Bleeding 244
m
Medical and Surgical Illnesses Complicating Pregnancy 246
■ Hematological Disorders in Pregnancy 246; • Anemia in Pregnancy 246; • Iron Deficiency Anemia 248;
• Megaloblastic Anemia 253; • Dimorphic Anemia 255; • Aplastic Anemia 255; • Hemoglobinopathies 255; • Sickle Cell Hemoglobinopathies 256; • Thalassemia Syndromes 257; • Platelet Disorders 257; ■ Heart Disease in Pregnancy 259; • General Management 260; • Management during Labor 261; • Specific Heart Disease during Pregnancy and the Management 262; ■ Diabetes Mellitus and Pregnancy 265; • Gestational Diabetes Mellitus (GDM) 265; • Overt Diabetes 267; ■ Thyroid Dysfunction and Pregnancy 273; ■ Jaundice in Pregnancy 275; ■ Viral Hepatitis 275; ■ Epilepsy in Pregnancy 277; ■ Asthma in Pregnancy 278;
■ Systemic Lupus Erythematosus (SLE) 280; ■ Tuberculosis in Pregnancy 280; ■ Syphilis in Pregnancy 281;
■ Parasitic and Protozoa! Infestations in Pregnancy 283; ■ Pyelonephritis in Pregnancy 284; • Asymptomatic Bacteriuria (ASB) 285; ■ Viral Infections in Pregnancy 286; ■ Human Immunodeficiency Virus (HIV) Infection and Acquired Immunodeficiency Syndrome (AIDS) 288; ■ COVID-19 in Pregnancy 291; ■ Surgical Illness during Pregnancy 291; ■ Acute Pain in Abdomen during Pregnancy 292; ■ Headache in Pregnancy 293;
■ Acute Fatty Liver in Pregnancy 293
Bl !Gynecological Disorders in Pregnancy 294 ■ Abnormal Vaginal Discharge 294; ■ Congenital Malformation of the Uterus and Vagina 294; ■ Carcinoma Cervix with Pregnancy 295; • Treatment 295; ■ Leiomyomas with Pregnancy 296; • Treatment 296;
■ Ovarian Tumor in Pregnancy 296; ■ Retroverted Gravid Uterus 297; ■ Morbid Anatomic Changes 298;
• Treatment 298; ■ Genital Prolapse in Pregnancy 298; • Treatment 298
m
!Preterm Labor and Birth, Preterm Rupture of the Membranes, Prolonged Pregnancy, Intrauterine Fetalpeath 300
■ Preterm Labor and Birth 300; • Etiology 300; • Management of Preterm Labor and Birth 302;
• Prevention of Preterm Labor 302; • Measures to Arrest Preterm Labor 302; ■ Management in Labor 302; ■ Prelabor Rupture of the Membranes (PROM) 304; • Management 305; ■ Prolonged and Post-term Pregnancy 306; • Diagnosis 307; • Management 308; ■ Intrauterine Fetal Death (IUFD) 31 O;
• Etiology 31 O; • Diagnosis 311; • Recommended Evaluation for a Stillbirth 311; • Management 311
m .
Complicated Pregnancy 314
■ Pregnancy with Prior Cesarean Delivery (CD) 314; • Integrity of the Scar 314; • Evidences of Scar Rupture (or Scar Dehiscence) during Labor 315; • Management of a Pregnancy with Prior CD 316; • Vaginal Birth after Previous (CD) 316; ■ Red Cell Alloimmunization 318; • Fetal Affection by the Rh Antibody 320;
■ Manifestations of Hemolytic Disease of the Fetus and Newborn (HDFN) 320; • Prevention of Rh-D Alloimmunization 321; ■ Antenatal Investigation Protocol of Rh-negative Mothers 323; ■ Plan of Delivery 324; • Prognosis 326; ■ Exchange Transfusion in the Newborn 326; ■ Grand Multipara 326; ■ Elderly Primigravida 327; ■ Bad Obstetric History (BOH) 328; • Investigations and Management 328;
■ Obesity in Pregnancy 329
Im Contents
, Contracted Pelvis 331
■ Asymmetrical or Obliquely Contracted Pelvis 333; ■ Mechanism of Labor in Contracted Pelvis with Vertex Presentation 333; ■ Diagnosis of Contracted Pelvis 334; ■ Disproportion 336; • Diagnosis of Cephalopelvic Disproportion (CPD) at the Brim 336; ■ Effects of Contracted Pelvis on Pregnancy and Labor 337; ■ Management of Contracted Pelvis (Inlet Contraction) 338; ■ Trial Labor 338; ■ Midpelvic and Outlet Disproportion 339
Abnormal Uterine Action 340
■ Uterine Inertia (Hypotonic Uterine Dysfunction) 341; ■ lncoordinate Uterine Action 342; ■ Precipitate Labor 344; ■ Tonic Uterine Contraction and Retraction 344
• Complicated Labor: Malposition, Malpresentation and Cord Prolapse 347
■ Occiput Posterior (OP) Position 347; • Diagnosis 348; • Mechanism of Labor 349; • Course of Labor 351; • Management of Labor 351; • Arrested Occiput Posterior Position 352; ■ Deep Transverse Arrest (OTA) 353; ■ Manual Rotation for Occiput Posterior Position 353; ■ Breech Presentation 355; • Varieties 355; • Etiology of Breech Presentation 355; • Diagnosis of Breech Presentation 356; • Mechanism of Labor in Breech Presentation 356; • Complications of Vaginal Breech Delivery 358; • Antenatal Management 359;
• Management of Vaginal Breech Delivery 361; • Assisted Breech Delivery 361; • Management of Complicated Breech Delivery 365; ■ Face Presentation 367; • Mechanism of Labor 368; • Diagnosis 368; • Management 370; • Vaginal Delivery 370; ■ Brow Presentation 371; ■ Transverse Lie 371;
• Diagnosis 372; • Clinical Course of Labor 372; ■ Management of Shoulder Presentation 374;
■ Unstable Lie 374; ■ Compound Presentation 374; ■ Cord Prolapse 375; • Management 376
Prolonged Labor, Obstructed Labor, Dystocia Caused by Fetal Anomalies 378
■ Prolonged Labor 378; • Treatment 380; ■ Obstructed Labor 381; • Treatment 382; • Shoulder Dystocia 383; ■ Dystocia Caused by Fetal Anomalies 383; • Hydrocephalus 383; ■ Neural Tube Defects (NTD) 384; • Anencephaly 384; ■ ConjoinedTwins 385
Complications of the Third Stage of Labor 386
■ Postpartum Hemorrhage (PPH) 386; ■ Primary Postpartum Hemorrhage 386; • Causes 386; • Prevention 387; • Management ofThird-stage Bleeding 388; • Steps of Manual Removal of Placenta 388; • Management ofTrue Postpartum Hemorrhage 389; • Actual Management 390; ■ Secondary Postpartum Hemorrhage 393; ■ Retained Placenta 394; • Management 394; ■ Inversion of the Uterus 396
• Injuries to the Birth Canal
■ Vulva 398; ■ Perineum 398; • Management 398; ■ Vagina 399; ■ Cervix 400; ■ Rupture of the Uterus 401; • Etiology 402; • Pathology 403; • Diagnosis 404; ■ Visceral Injuries 405
• Abnormalities of the Puerperium
398
■ Pelvic Hematoma 400; • Management 405;
407
■ Puerperal Pyrexia 407; ■ Puerperal Sepsis 407; • Pathology 408; • Clinical Features 408; • Investigations of Puerperal Pyrexia 409; • Treatment 410; ■ Subinvolution 411; ■ Urinary Complications in Puerperium 411; ■ Breast Complications 412; ■ Puerperal VenousThrombosis 413; • Prophylaxis and Management 414;
■ Pulmonary Embolism 415; ■ Obstetric Palsies 416; ■ Puerperal Emergencies 416; ■ Psychiatric Disorders during Puerperium 417; ■ Psychological Response to Perinatal Deaths and Management 418
The Term Newborn Infant 419
■ Physical Features of the Newborn 419; ■ Immediate Care of the Newborn 421; ■ Infant Feeding 422; • Breastfeeding 423; • Artificial Feeding 427; • Childhood Immunization Program 428
Low Birth Weight Baby 429
■ Preterm Baby 430; • Complications of a Preterm Neonate 430; • Management 432; • Care of a Preterm Neonate 432; ■ Fetal Growth Restriction (FGR) 434; • Management 437
m 'Diseas!S,£f the Fet;!S and the New orn Contents ■ Perinatal Asphyxia 441; • Fetal Respiration 441; • Clinical Features 442; • Management 443;
■ Respiratory Distress in the Newborn 445; ■ Transient Tachypnea of the Newborn(TTN) 448; ■ Meconium Aspiration Syndrome(MAS) 448; ■ Jaundice of the Newborn 449; • Management of Jaundice in the Newborn 451; ■ Hemolytic Disease of the Newborn 452; • ABO Group Incompatibility 452; ■ Bleeding
Disorders in the Newborn 453; ■ Anemia in the Newborn 453; ■ Seizures in the Newborn 454; ■ Birth Injuries of the Newborn 455; • Injuries to the Head 455; • lntracranial Hemorrhage 456; • Other Injuries 457;
■ Perinatal Infections 458; • Mode of Infection 458; • Ophthalmia Neonatorum 459; • Skin Infections 460; • Necrotizing Enterocolitis 461; • Mucocutaneous Candidiasis 461; ■ CongenitalMalformations and Prenatal Diagnosis 463; • Down's Syndrome (Trisomy 21) 463; ■ Surgical Emergencies 463; ■ Nonimmune Fetal Hydrops 465
m
IPharmacotherapeutics in Obstetrics 467
■ Oxytocics in Obstetrics 467; • Oxytocin 467; • Methods of Administration 468; • Ergot Derivatives 470; • Prostaglandins (PGs) 470; ■ AntihypertensiveTherapy 473; ■ Diuretics 473; ■ Tocolytic Agents 473;
■ Anticonvulsants 474; ■ Anticoagulants 474; ■ Maternal Drug Intake and Breastfeeding 475; ■ Fetal Hazards of Maternal Medication duringPregnancy 477; • Teratology andPrescribing in Pregnancy 477;
■ Analgesia and Anesthesia in Obstetrics 479; • Anatomical and Physiological Considerations 479; • Analgesia during Labor and Delivery 480; • Inhalation Methods 481; • Regional ( Neuraxial) Anesthesia 482; • Infiltration Analgesia 484; • General Anesthesia forCesarean Section 484
m
[1ndtiction ohabor 487
■ Methods of Induction of Labor 488; • Medical Induction 488; • Surgical Induction 490; the Membranes (LRM) 491; • Stripping the Membranes 491; ■ Combined Method 492
jPopulation Dynamics and Control of Co, nception
m
• Low Rupture of
496
■ Control of Contraception 496; • Family Planning 496; • Contraception 497; ■ Methods of Contraceptions 497; • TemporaryMethods 497; • IntrauterineContraceptive Devices 497; ■ Steroidal Contraceptions 504; • Combined Oral Contraceptives (Pills) 504; • Centchroman (Chhaya/Saheli) 509;
• Progestogen-only Contraceptions 509; • Emergency Contraception (CE) 511; • Summary of Oral Contraceptives 512; ■ Drug Interaction and Hormonal Contraception 513; ■ Sterilization 513;
• Couple Counseling 513; • Male Sterilization 514; • Female Sterilization 515; ■ Barrier Methods 518;
• Condom(Male) 519; • FemaleCondom(Femidom) 519; • Diaphragm 519; • VaginalContraceptives 520; • Fertility Awareness Method 520; • Contraceptive Counseling andPrescription 521; • Prescription 521;
■ Ongoing Trials and Selective Availability 522; • Transcervical Sterilization 522
m
10perative Obstetrics 523
■ Dilatation and Evacuation ( D & E) 523; • One-stage Operation 523; • Two-stage Operation 524; • Management of Uterine Perforation 525; ■ Suction Evacuation 525; ■ Vacuum Aspiration 526;
■ Episiotomy 527; • Types 527; • Steps, Postoperative Care 528; • Complications 529; ■ Operative Vaginal Delivery 529; • Forceps 530; • Types of Forceps Operation 530; • Low Forceps Operation 532; Outlet Forceps Operation 535; Midforceps Operation 535; • Difficulties in Forceps Operation 535;
• Kiel land's Forceps 536; • Complications of Forceps Operation 537; ■ Ventouse 537; ■ Version 540;
• External Cephalic Version 540; • Internal Version 542; ■ Cesarean Delivery (CD) 542; • Indications 543; • Lower Segment CS 544; • PostoperativeCare 547; • Classical Cesarean Section 548; • Complications of
CS: lntraoperative, Postoperative 549; ■ Destructive Operations 550; • Craniotomy 550; • Cleidotomy 552; • Postoperative Care 552; ■ Symphysiotomy 552
m
Safe Motherhood, Epidemiology of O s.tetrics
554
■ Safe Motherhood 554; ■ Clinical Causes of Maternal Deaths 554; ■ Country Targets 555; ■ Sustainable Development Goals ( SDGs) 556; ■ Reproductive and Child Health ( RCH) Care 557; ■ Epidemiology of Obstetrics 558; • MaternalMortality 558; • Maternal Near Miss 561; • MaternalMorbidity 561;
• PerinatalMortality 561; • Important Causes of PerinatalMortality andMain Interventions 563; • Stillbirths 563; • Neonatal Deaths 563
!I Contents
• Special Topics in Obstetrics 565
■ lntrapartum Fetal Evaluation 565; • Methods of Fetal Evaluation 565; ■ Nonreassuring Fetal Status (NRFS) 570; • Management 570; ■ Shock in Obstetrics 572; • Pathophysiology 572; • General Changes 572; • Classification of Shock 574; ■ Management of Shock 575; • Endotoxic Shock 576;
■ Acute Kidney Injury (AKI) 578; • Causes 578; • Management in Obstetrics 579; ■ Blood Coagulation Disorders in Obstetrics 580; • Normal Blood Coagulation 582; • Pathology of Acquired Coagulopathy 582;
• Investigations 583; • Treatment 584; ■ High-risk Pregnancy 585; • Management of High-risk Cases 587; ■ Immunology in Obstetrics 588; ■ Critical Care in Obstetrics 590
' t Current Topics in Obstetrics 592
■ Medical Ethics 592; ■ Effective Clinical Communication 592; ■ Pregnancy Following Assisted Reproductive Technology (ART) 593; ■ Antibiotic Prophylaxis in Cesarean Section 594; ■ Day-care Obstetrics 594; ■ Legal and Ethical Issues in Obstetric Practice 594; ■ The Preconception Counseling Prenatal Diagnostic Techniques 595; ■ Audit in Obstetrics 595; ■ Umbilical Cord Blood Stem Cells in Transplantation and Regenerative Medicine 596; • Stem Cells and Therapies in Obstetrics 596
Imaging in Obstetrics (USG, MRI, CT, Radiology), Amniocentesis and Guides to Clinical Tests 598
■ Ultrasound in Obstetrics 598; • Three-dimensional Ultrasonography 599; • FirstTrimester Ultrasonography 599; • Midtrimester Ultrasonography 601; • Third Trimester Ultrasonography 602; • lntrapartum Sonography 603; ■ Magnetic Resonance Imaging (MRI) 603; ■ Computed Tomography (CT) in Obstetrics 604; ■ Radiology in
Obstetrics 604; ■ Amniocentesis 605; ■ Guides to Clinical Tests 606; ■ Tests for Blood Coagulation Disorders 607; • Collection of Blood Sample 607; • Samples for Blood Sugar Estimation 608; ■ Cervical and Vaginal Cytology 608
Practical Obstetrics
■ Obstetrics Instruments 609; ■ Drugs 620; ■ Specimens 622;
609
■ Imaging Studies 627; ■ Suture Materials 629
Index 631
Competency-Based NMC Curriculum
OGl.1 Define and discuss birth rate, maternal mortality and morbidity
OGl.2 Define and discuss perinatal mortality and morbid-ity including perinatal and neonatal mortality and morbidity audit
OGl.3 Define and discuss still birth and abortion
OG2.1 Describe and discuss the development and anato-my of the female reproductive tract, relationship to other pelvic organs, applied anatomy as related to obstetrics and gynecology
OG3.1 Describe the physiology of ovulation, menstrua-tion, fertilization, implantation and gametogenesis
OG4.1 Describe and discuss the basic embryology of fetus, factors influencing fetal growth and develop-ment, anatomy and physiology of placenta, and teratogenesis
OG5.1 Describe, discuss and identify pre-existing medical disorders and discuss their management; discuss evidence-based intrapartum care
OG5.2 Determine maternal high-risk factors and verify immunization status
OG6.1 Describe, discuss and demonstrate the clinical fea-tures of pregnancy, derive and discuss its differen-tial diagnosis, elaborate the principles underlying and interpret pregnancy tests.
OG7.1 Describe and discuss the changes in the genital tract, cardiovascular system, respiratory, hemato-logy, renal and gastrointestinal system in pregnancy
OG8.1 Enumerate, describe and discuss the objectives of antenatal care, assessment of period of gestation; screening for high-risk factors.
OG8.2 Elicit document and present an obstetric history including menstrual history, last menstrual period, previous obstetric history, comorbid conditions, past medical history and surgical history
OG8.3 Describe, demonstrate, document and perform an obstetrical examination including a general and abdominal examination and clinical monitoring of maternal and fetal wellbeing;
OG8.4 Describe and demonstrate clinical monitoring of maternal and fetal wellbeing
OG8.5 Describe and demonstrate pelvic assessment in a model
OG8.7 Enumerate the indications for and types of vac-cination in pregnancy
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Chapter
Number 38
38
16 22
1
2
3 4
20 39
10
39
5 6 7 15
41
5
10 11 12 39
8 10
23
8 10
11
10 11
9 24
10 20
.. ' . 554-564
554-564
153-166 310-313
1-15
16-25
26-37 38-42
246-293 565-591
93
565-591
43-54 55-60 61-68 149-152 598-608
43-54
86-94 95-101 102-107 565-570
69-75 86-94
314-330
69-75 86-94
95-101
86-94 95-101
79-85 331-339
93
246-293
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OG8,8 Enumerate the indications and describe the inves-tigations including the use of ultrasound in the initial assessment and monitoring in pregnancy
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,-w, -
7 61-66 41 598-608
OG9.1 Classify, define and discuss the etiology and management of abortions including threatened, incomplete, inevitable, missed and septic
OG9.2 Describe the steps and observe/assist in the per-formance of an MTP evacuation
OG9.3 Discuss the etiology, clinical features, differential diagnosis of acute abdomen in early pregnancy (with a focus on ectopic pregnancy) and enumer-ate the principles of medical and surgical manage-ment
OG9.4 Discuss the clinical features, laboratory investiga-tions, ultrasonography, differential diagnosis, prin-ciples of management and follow up of gestational trophoblastic neoplasms
OG9.5 Describe the etiopathology, impact on maternal and fetal health and principles of management of hyperemesis gravidarum
OG10.1 Define, classify and describe the etiology, patho-genesis, clinical features, ultrasonography, differ-ential diagnosis and management of antepartum hemorrhage in pregnancy
OG11.1 Describe the etiopathology, clinical features; diag-nosis and investigations, complications, principles of management of multiple pregnancies
OG12.1 Define, classify and describe the etiology and pathophysiology, early detection, investigations; principles of management of hypertensive disor-ders of pregnancy and eclampsia, complications of eclampsia.
OG12.2 Define, classify and describe the etiology, patho-physiology, diagnosis, investigations, adverse effects on the mother and fetus and the manage-ment during pregnancy and labor, and complica-tions of anemia in pregnancy
OG12.3 Define, classify and describe the etiology, patho-physiology, diagnosis, investigations, criteria, adverse effects on the mother and fetus and the management during pregnancy and labor, and complications of diabetes in pregnancy
OG12.4 Define, classify and describe the etiology, patho-physiology, diagnosis, investigations, criteria, adverse effects on the mother and fetus and the management during pregnancy and labor, and complications of heart diseases in pregnancy
OG12.5 Describe the clinical features, detection, effect of pregnancy on the disease and impact of the
disease on pregnancy complications and manage-ment of urinary tract infections in pregnancy
OG12.6 Describe the clinical features, detection, effect of pregnancy on the disease and impact of the
disease on pregnancy complications and manage-ment of liver disease in pregnancy
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153-189
166-169
153-189 292-293
182-189
149-152
153-189 230-245
190-208
209-229
246-293
246-293
246-293
246-293
246-293
Competency-Based NMC Curriculum !1
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OG12.7 Describe and discuss screening, risk factors, man-agement of mother and newborn with HIV
OG12.8 Describe the mechanism, prophylaxis, fetal compli-cations, diagnosis and management of isoimmuni-zation in pregnancy
OG13.1 Enumerate and discuss the physiology of normal labor, mechanism of labor in occipito-anterior presentation; monitoring of labor including par-togram; conduct of labor, pain relief; principles of induction and acceleration of labor; management of third stage of labor
OG13.2 Define, describe the causes, pathophysiology, diagnosis, investigations and management of pre-term labor, PROM and postdated pregnancy
OG13.3 Observe/assist in the performance of an artificial rupture of membranes
OG14.1 Enumerate and discuss the diameters of maternal pelvis and types
OG14.2 Discuss the mechanism of normal labor, define and describe obstructed labor, its clinical features; prevention; and management
OG14.3 Describe and discuss rupture uterus, causes, diag-nosis and management
OG14.4 Describe and discuss the classification; diagnosis; management of abnormal labor
OG15.1 Enumerate and describe the indications and steps of common obstetric procedures, technique and complications: Episiotomy, vacuum extraction; low forceps; cesarean section, assisted breech delivery; external cephalic version; cervical cerclage
OG15.2 Observe and assist in the performance of an episiotomy and demonstrate the correct suturing technique of an episiotomy in a simulated environ-ment. Observe/assist in operative obstetrics cases including-CS, forceps, vacuum extraction, and breech delivery
OG16.1 Enumerate and discuss causes, prevention, diag-nos is, management, appropriate use of blood and blood products in postpartum hemorrhage
OG16.2 Describe and discuss uterine inversion-causes, prevention, diagnosis and management.
OG16.3 Describe and discuss causes, clinical features, diagnosis, investigations; monitoring of fetal well-being, including ultrasound and fetal Doppler; principles of management; prevention and coun-seling in intrauterine growth retardation
OG17.1 Describe and discuss the physiology of lactation
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20 246-293
23 314-330
13 108-138 26 347-377 27 378-385 479A85
34
35 487A95
22 300-313
35 487A95
9 79-85 24 33H39
13 108-138 24 33H39 25 340-346 27 378-385
29 398-406
27 378-385
26
347-377
523-553
37
523-553
37
28 386-397 39 584-585
28 396-397
33 441-466
14 143-144
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OG17.2 Counsel in a simulated environment, care of the breast, importance and the technique of breast-feeding
OG17.3 Describe and discuss the clinical features, diagnosis and management of mastitis and breast abscess
OG18.1 Describe and discuss the assessment of maturity of the newborn, diagnosis of birth asphyxia, principles of resuscitation, common problems.
OG18.3 Describe and discuss the diagnosis of birth asphyxia
OG18.4 Describe the principles of resuscitation of the newborn and enumerate the common problems encountered
OG19.1 Describe and discuss the physiology of puerperi-um, its complications, diagnosis and management; counseling for contraception, puerperal steriliza-tion
OG19.2 Counsel in a simulated environment, contracep-tion and puerperal sterilization
OG19.3 Observe/assist in the performance of tubal ligation
OG19.4 Enumerate the indications for, describe the steps in and insert and remove an intrauterine device in a simulated environment
OG20.1 Enumerate the indications and describe and discuss the legal aspects, indications, methods for first and second trimester MTP; complications and management of complications of Medical Termina-tion of Pregnancy
OG20.2 In a simulated environment administer informed consent to a person wishing to undergo Medical Termination of Pregnancy
OG20.3 Discuss Preconception and Prenatal Diagnostic Techniques (PC & PNDT) Act 1994 and its amend-ments
OG21.1 Describe and discuss the temporary and per-manent methods of contraception, indications, technique and complications; selection of patients, side effects and failure rate including OCs, male contraception, emergency contraception and IUCD
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33
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14
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36
419-428
412-413
419-428 429-440 441-466
441-466
441-466
139-148 407-418 497-523
496-522
496-522
496-522
166-169
166-169 592-597
496-522
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Abbreviations
AAP AC
ACHOIS
ACA ACOG
ACOR ADA AED AFI AFP AFV AGA AGS ALT AMTSL ANF APH aPLs APTT ARDS AREDV ARM ART ASD ASRM AST ATP ATS AUA
j32GP-1 BMI
BPD BPD BPP CBG CCF CDC
cff-DNA CIN
: American Academy of Pediatrics : Abdominal Circumference
: Australian Carbohydrate Intolerance in Pregnancy Study
: Anti-cardiolipin Antibodies
: American College of Obstetricians and Gynecologists
: American College of Radiology : American Diabetes Association : Antiepileptic Drug
: Amniotic Fluid Index : Alpha-fetoprotein
: Amniotic Fluid Volume
: Average for Gestational Age : Anti-gas Gangrene Serum
: Alanine Amniotransferase
: Active Management ofThird Stage of Labor : Atrial Natriuretic Factor
: Antepartum Hemorrhage
: Anti-phospholipid Antibodies
: Activated Partial Thromboplastin Time : Acute Respiratory Distress Syndrome
: Absent or Reversed End-diastolic Velocity : Artificial Rupture of Membranes
: Assisted Reproductive Technology : Atrial Septa! Defect
: American Society of Reproductive Medicine : Aspartate Amniotransferase
: Adenosine Tri phosphate : Anti-tetanus Serum
: Abnormal Uterine Action
: 132 Glycoprotein-1 : Body Mass Index
: Biparietal Diameter
: Broncho-pulmonary Dysplasia : Biophysical Profile
: Corticosteroid-binding Globulin : Congestive Cardiac Failure
: Centers for Disease Control : Cell-free fetal DNA
: Cervical lntraepithelial Neoplasia
CIRCI : Critical Illness-related Corticosteroid Insuficiency
CMQCC : California Maternal Quality Care Collaboration
CMV : Cytomegalovirus
co : Cardiac Output
COCs : Combined Oral Contraceptives
cox : Cyclo-oxygenase CP : Cerebral Palsy
CPAP : Continuous Positive Airway Pressure CPD : Cephalopelvic Disproportion
CPK : Creatinine Phosphokinase CPR : Cerebroplacental Ratio CPT : Complete Perinea! Tear
CRH : Corticotropin-releasing Hormone CRL : Crown-rump Length
CRP : (-reactive Protein
CRS : Congenital Rubella Syndrome
cs : Cesarean Section
CSE : Combined Spinal Epidural CST : Contraction Stress Test
CT : Computed Tomography CTG : Cardiotocography
CTPA : Computed Tomographic Pulmonary
Angiography
cus : Cranial Ultrasonography CVP : Central Venous Pressure CVS : Chorionic Villus Sampling
CVS : Congenital Vericella Syndrome CXR : Chest X-ray
D&E : Dilatation and Evacuation DID : Diamniotic-Dichorionic
DIM : Diamniotic-Monochorionic DBP : Diastolic Blood Pressure
DFMC : Daily Fetal Movement Counting DFMCR : Daily Fetal Movement Counting Rate
DIC : Disseminated lntravascular Coagulopathy DIPSI : Diabetes in Pregnancy Societies of India DMPA : Depot Medroxyprogesterone Acetate OTA : Deep Transverse Arrest
DV : Ductus Venosus
DVP : Deepest Vertical Pocket
mm Abbreviations
DVT : Deep Vein Thrombosis EACA : Epsilon Aminocaproic Acid EAS : External Anal Sphincter ECG : Electrocardiography
ECV : External Cephalic Version EDD : Expected Date of Delivery EFM : Electronic Fetal Monitoring EFW : Estimated Fetal Weight EmOC : Emergency Obstetric Care
EmONC : Emergency Obstetric and Newborn Care ENG : Etonogestrel
EPF : Early Pregnancy Factor
ERPC : Evacuation of Retained Products of Conception
ESC : Embryonic Stem Cell
ESI : Endocrine Society of India
ESRE : European Society of Reproductive and Endocrinology
EUA : Examination under Anesthesia FBS : Fetal Blood Sampling
FDA : Food and Drug Administration FDP : Fibrin Degradation Products FFA : Free Fatty Acid
ffDNA : free-fetal DNA
FFP : Fresh-frozen Plasma FGR : Fetal Growth Restriction FHR : Fetal Heart Rate
FHS : Fetal Heart Sound
FIGO : International Federation of Gynecology and Obstetrics
hCG : Human Chorionic Gonadotropin HCS : Hemopoietic Stem Cells
hCT : Human ChorionicThyrotropin
HDFN : Hemolytic Disease of the Fetus and Newborn HDL : High-density Lipoprotein
HELLP : Hemolysis, Elevated Liver Enzymes, Low Platelet Counts
HIE : Hypoxic-ischemic Encephalopathy HIV : Human Immunodeficiency Virus HLA : Human Leukocyte Antigen
HMD : Hyaline Membrane Disease HPL : Human Placental Lactogen HR : Heart Rate
IAS : Internal Anal Sphincter
IUA : lncoordinate Uterine Action ICF : Intracellular Fluid
ICH : lntracranial Hemorrhage
ICOG : Indian College of Obstetricians & Gynaecologists
ICU : Intensive Care Unit
IFM : lntrapartum Fetal Monitoring IGF-1 : Insulin Growth Factor-1
lgG : lmmunoglobulin G IOL : Induction of Labor
IPS : lntrapartum Ultrasonography IPT : lntraperitoneal Transfusion ITS : Indian Thyroid Society
ITU : Intensive Care Unit
IUCD : Intrauterine Contraceptive Device IUD : Intrauterine Device
FISH : Fluorescence in situ Hybridization FL : Femur Length
FMH : Fetomaternal Hemorrhage
FOGSI : Federation of Obstetrics and Gynaecological Societies of India
FRU : First Referral Unit
FSH : Follicle-stimulating Hormone GA : Gestational Age
GBS : Group B Streptococcus
GDM : Gestational Diabetes Mellitus
GH-PE : Gestational Hypertension-Pre-eclampsia GLUT : Glucose Transporter
GMH : Germinal Matrix Hemorrhage GnRH : Gonadotropin-releasing Hormone GTN : Gestational Trophoblastic Neoplasia GTN : Glyceryl Trinitrate
GTT : Glucose Tolerance Test
HAART : Highly Active Anti-retroviral Therapy Hb : Hemoglobin
HC : Head Circumference
IUFD IUGR IUT IVC IVH IVlg IVS IVT JSY KB KMC
L:S Ratio LA
LAM LARC LBW LDH LDL LGA LH
: Intrauterine Fetal Death
: Intrauterine Growth Restriction : Intrauterine Transfusion
: Inferior Vena Cava
: lntraventricular Hemorrhage : Intravenous lmmunoglobulin : lntervillous Space
: lntravascularTransfusion : Janani Suraksha Yojana
: Kleihauer-Betke
: Kangaroo Mother Care
: Lecithin-Sphingomyelin Ratio : Lupus Anticoagulant
: Lactational Amenorrhea
: Long-acting Reversible Contraception : Low Birth Weight
: Lactic Dehydrogenase
: Low-density Lipoprotein : Large for Gestational Age : Luteinizing Hormone
LMA LMP LMWH LNG-IUS LOA LOP LOT LPD
LSA LSCS LVP M/M MAP MCA MCU MDGs MFMU MLCK MMR MOMs MODS MPSS MRA MRI MRP MSAFP MTHFR MVA NCDs NEC NICE NICHD
NICU NIPT NK NO NPN NREM NRFS NST NSV NT NTD OA oc OP OT OVD
PAPP-A
: Left Mentoanterior
: Last Menstrual Period
: Low Molecular Weight Heparin
: Levonorgestrel-lntrauterine System : Left Occiput Anterior
: Left Occiput Posterior
: Left Occiput Transverse : Luteal Phase Defect
: Left Sacrum Anterior
: Lower Segment Cesarean Section : Largest Vertical Pocket
: Monoamniotic-Monochorionic : Mean Arterial Pressure
: Middle Cerebral Artery : Microcirculatory Unit
: Millennium Development Goals : Maternal Fetal Medicine Unit
: Myocin Light Chain Kinase : Maternal Mortality Ratio
: Multiples of the Medians
: Multi-Organ Dysfunction Syndrome
: Massively Parallel DNA Shotgun Sequencing : Magnetic Resonance Angiography
: Magnetic Resonance Imaging : Manual Removal of Placenta
: Maternal Serum Alphafeto-protein
: Methylenetetrahydrofolate Reductase : Manual Vacuum Aspiration
: Non-communicable Diseases : Necrotizing Enterocolitis
: National Institute of Clinical Excellence
: National Institute of Child Health and Development
: Neonatal Intensive Care Unit : Noninvasive Prenatal Test
: Natural Killer Cells : Nitric Oxide
: Non-protein Nitrogen
: Non-rapid Eye Movement
: Non-reassuring Fetal Status : Non-stress Test
: No-scalpel Vasectomy : NuchalTranslucency
: Neural Tube Defect : Occiput Anterior
: Oral Contraceptive : Occiput Posterior
: OcciputTransverse
: Operative Vaginal Delivery
: Pregnancy-associated Plasma Protein-A
Abbreviations -PBI : Protein-bound Iodine
PCA : Patient-controlled Analgesia PCOS : Polycystic Ovarian Syndrome PCR : Polymerase Chain Reaction
PCWP : Pulmonary Capillary Wedge Pressure PDA : Patent Ductus Arteriosus
PDS : Polydioxanone
PE : Pulmonary Embolism PG : Phosphatidylglycerol
PGD : Pre-implantation Genetic Diagnosis PGN : Progestin
PGs : Prostaglandins Pl : Pulsatility Index
PID : Pelvic Inflammatory Disease
PIH : Pregnancy-induced Hypertension PO : Per Oral
POD : Pouch of Douglas
POP : Persistent Occiput Posterior PPBs : Postprandial Blood Sugar PPH : Postpartum Hemorrhage
PPIUCD : Postpartum Intrauterine Contraceptive Device PPTCT : Prevention of Parent-to-child Transmission PRES : Posterior Reversible Encephalopathy
Syndrome
PROM : Prelabor Rupture of Membranes PSV : Peak Systolic Velocity
PT : ProthrombinTime PTB : Preterm Birth
PTH : Parathyroid Hormone PTL : Preterm Labor
PVL : Periventricular Leukomalacia PVR : Pulmonary Vascular Resistance
RAAS : Renin-Angiotensin-Aldosterone System RBC : Red Blood Cells
RCOG : Royal College of Obstetricians and Gynaecologists
RDS : Respiratory Distress Syndrome REDF : Reversed End Diastolic Flow REM : Rapid Eye Movement
RFA : Radiofrequency Ablation Rhlg : Rhesus lmmunoglobulin RI : Resistance Index
RMNCH : Reproductive, Maternal, Newborn, Child Health
RNTCP : Revised National Tuberculosis Control Programme
ROA : Right Occiput Anterior ROP : Right Occiput-Posterior ROS : Reactive Oxygen Species ROT : Right Occiput Transverse
ll Abbreviations
RR : Respiratory Rate RSP : Right Sacroposterior
SBP : Systolic Blood Pressure SC : Subcutaneous
SCJ : Squamocolumnar Junction SOG : Sustainable Development Goals SOH : Subdural Hemorrhage
S/0 Ratio : Systolic/Diastolic Ratio SFH : Symphysio-fundal Height SGA : Small for Gestational Age
SIRS : Systemic Inflammatory Response Syndrome SLE : Systemic Lupus Erythematosus
SMI : Safe Motherhood Initiative
sv : Stroke Volume
SVR : Systemic Vascular Resistance SVO : Spontaneous Vaginal Delivery TA : Transabdominal
TAS : Transabdominal Sonography TBG : Thyroxin-binding Globulin TC : Transcervical
TOI : Total Dose Infusion
TOO : Transverse Diameter of the Outlet TGF : Transforming Growth Factor-
TNFa : Tumor Necrosis Factor-a TOLAC : Trial of Labor after Cesarean TPS : Transperineal Sonography TRAP : Twin Reverse Arterial Perfusion TSH : Thyroid-stimulating Hormone
TTN : TransientTachypnea of the Newborn TTTS : Twin-to-Twin Transfusion Syndrome TVS : Transvaginal Sonography
UAE : Uterine Artery Embolization UE : Unconjugated Estriol
UHC : Universal Health Coverage USG : Ultrasonography
UTI : Urinary Tract Infection UV : Umbilical Vein
V/Q : Ventilation/Perfusion Ratio VBAC : Vaginal Birth after Cesarean VBAC-TOL: VBAC-Trial oflabor
VEGF : Vascular Endothelial Growth Factor VLBW : Very Low Birth Weight
VSO : Ventricular Septal Defect
vus : Venous Ultrasonography VVF : Vesicovaginal Fistula
WHO : World Health Organization
Atlas: Steps of LSCS
Operation trolley with all the instruments for cesarean section. (1) Towels for drapping, (2) Suction tube (with cannula), (3) Electrodiathermy set, (4) Mops (large swabs), (5) Towel clips, (6) Kidney dish, gauze pieces, (7) Bowl with povidone iodine, (8) Empty bowl, (9) Needle holders (curved and straight variety), (10) Sponge holding forceps, (11) Knives, (12) Dissecting forceps (toothed and non-toothed), (13) Scissors (3), (14) Artery forceps (short variety), (15) Kocher's forceps, (16) Allis tissue forceps,
(17) Lanes tissue forceps, (18) Little Wood's forceps, (19) Green Armytage forceps, (20) Obstetric forceps, (21) Doyen's retractor, (22) Suture packets.
Step 1: Abdomen is painted with povidone iodine solution and is draped with sterile towels. Only the area of operation is exposed.
Step 2: Abdomen is opened by modified Pfannenstiel incision. Loose peritoneum of the uterovesical pouch is being stretched out and shown. It is incised transversely.
mm Atlas: Steps of LSCS
Step 3: Uterine muscle incision (low transverse) is made on the lower segment of the uterus (LSCS). The amniotic membrane is seen to bulge out with the pressure of amniotic fluid. This amniotic membrane needs to be ruptured to deliver the baby. Doyen's retractor is seen in place.
Step 5: Delivery of the baby is on progress. It is to be done slowly. The head is delivered by elevation and flexion using the fingers to act as a fulcrum. Note that Doyen's retractor has been taken out.
Step 7: Baby is delivered slowly. The cord is clamped and cut in between. Baby is handed over to the neonatologist for immediate care of the newborn.
Step 4: Delivery of the head. The amniotic fluid is sucked out following rupture of the membranes. Doyen's retractor is removed. The head is delivered slowly with the fingers of the right hand, insinuated between the head and the lower uterine flap. Assistant applies some pressure on the fundus at this time.
Step 6: Delivery of the head in cesarean section. Suctioning of the mouth, pharynx, are being done gently before delivery of the trunk.
Step 8: Delivery of the placenta and membranes: Placenta is allowed to separate spontaneously. Placenta is delivered by traction on the cord (right hand). Simultaneously, the uterus is pushed upwards using the left hand. Note the abdominal retractor (Doyen's) is reintroduced.
Atlas: Steps of LSCS -k
Step 9: The uterine wound is seen following delivery. Usually four Allis's tissue forceps (Green Armytage forceps) are used to hold the incision margins, two (one each) on the angles of incision. Another two (one each) on the upper and lower uterine flap.
Step 10: Suturing of the uterine wound. It is done in two or three layers. It may be done keeping the uterus in the abdominal cavity or delivering it out (eventration). Suture material is No. 'O' chromic catgut or Vicryl-0 with round bodied needle. A continuous running suture taking deeper muscles is made. A similar suture is placed taking the superficial muscles overlapping the first layer. Nonclosure of the visceral peritoneum is preferred.
Step 11: Closure of the abdomen. The mops are removed and the number verified. Peritoneal toileting is done. Doyen's retractor is removed. The abdomen is closed in layers. The vagina is cleaned of blood and blood clots. A sterile vulval pad is placed.
Atlas: Steps of Low Forceps Delivery
Step 1: Left blade of the forceps is introduced first. The left handle is hold by the three fingers (index, middle and the thumb) of the left hand. Thumb pressure is used to introduce the blade under guidance of the fingers of the right hand.
Step 3: Direction of pull: First-downwards and backwards until the head is in perineum ➔ Straight and horizontal (seen) towards the operator.
Step 2: Locking of the blades. Blades are locked easily when applied correctly (bimalar, biparietal placement).
Step 4: Pull is now changed and directed upwards and forwards towards the mother's abdomen. The head is delivered slowly by extension.
Atlas: Steps of Low Forceps Delivery nm
Step 5: The blades are removed. Head is delivered slowly. Ritgen's maneuver is performed.
Step 7: Delivery of the trunk and that of the baby is done completely.
Step 6: Delivery of the shoulder. Note that the bisacromial diameter lies in the anteroposterior diameter of the outlet of the pelvis. Also note that the anterior shoulder is being released slowly from under the symphysis pubis.
Step 8: Immediate care of the newborn is done. Cord clamping and Apgar rating is done.
Anatomy of Female
Reproductive Organs
❖ External Genitalia ► Mons Veneris ► Labia Majora ► Labia Minora
► Clitoris
► Vestibule
► Perineum
❖ Internal Genitalia ► Vagina
► Uterus
► Fallopian Tube ► Ovary
❖ Muscles and Fascia in Relation to the
Pelvic Organs
► Pelvic Floor ► Perineum
► Pelvic Fascia
❖ Pelvic Cellular Tissue ❖ Female Urethra
❖ Urinary Bladder ❖ Pelvic Ureter
❖ Breasts
The reproductive organs in female are those which are concerned with copulation, fertilization, growth and development of the fetus and its subsequent exit to the outer world. The organs are broadly divided into:
♦ External genitalia ♦ Internal genitalia
♦ Accessory reproductive organs
EXTERNAL GENITALIA (Synonyms: Vulva, Pudendum)
The vulva or pudendum includes all the visible external genital organs in the perineum. Vulva consists of the following: the mons pubis, labia majora, labia minora, hymen, clitoris, vestibule, urethra and Skene's glands, Bartholin glands and vestibular bulbs {Fig. 1.1). It is
Prepuce
Clitoris
Frenulum
Labium majus
Fossa navicularis
Fig. 1.1: The virginal vulva.
Chapter 1: Anatomy of Female Reproductive Organs
therefore bounded anteriorly by mons pubis, posteriorly by the rectum, laterally by the genitocrural fold. The vulvar area is covered by keratinized stratified squamous epithelium.
I MONS VEN ERIS (MONS PUBIS)
It is the pad of subcutaneous adipose connective tissue lying in front of the pubis and in the adult female is covered by hair. The hair pattern (escutcheon) of most women is triangular with the base directed upwards.
I LABIA MAJORA
The vulva is bounded on each side by the elevation of skin and subcutaneous tissue which form the labia majora. They are continuous where they join medially to form the posterior commissure in front of the anus. The skin on the outer convex surface is pigmented and covered with hair follicle. The thin skin on the inner surface has sebaceous glands but no hair follicle. The labia majora are covered with squamous epithelium and contain sweat glands. Beneath the skin, there is dense connective tissue and adipose tissue. The adipose tissue is richly supplied with venous plexus which may produce hematoma, if injured during childbirth. The labia majora are homologous to the scrotum in the male. The round ligament terminates at its upper border.
I LABIA Ml NORA
They are two thin folds of skin, devoid of fat, on either side just within the labia majora. Except in the parous women, they are exposed only when the labia majora are separated. Anteriorly, they divide to enclose the clitoris and unite with each other in front and behind the clitoris to form the prepuce and frenulum respectively. The lower portion of the labia minora fuses across the midline to form a fold of skin known as fourchette. It is usually lacerated during childbirth. Between the fourchette and the vaginal orifice is the Iossa navicularis. The labia minora contain no hair follicles or sweat glands. The folds contain connective tissues, numerous sebaceous glands, erectile muscle fibers and numerous vessels and nerve endings. The labia minora are homologous to the penile urethra and part of the skin of penis in males.
I CLITORIS
It is a small cylindrical erectile body, measuring about 1.5-2 cm situated in the most anterior part of the vulva. It consists of a glans, a body and two crura. The clitoris consists of two cylindrical corpora cavernosa ( erectile tissue). The glans is covered by squamous epithelium and is richly supplied with nerves. The vessels of the clitoris are connected with the vestibular bulb and
are liable to be injured during childbirth. Clitoris is homologous to the penis in the male but it differs in being entirely separate from the urethra. It is attached to the undersurface of the symphysis pubis by the suspensory ligament.
I VESTIBULE
It is a triangular space bounded anteriorly by the clitoris, posteriorly by the fourchette and on either side by labia minora. There are four openings into the vestibule.
(a) Urethral opening: The opening is situated in the midline just in front of the vaginal orifice about 1-1.5 cm below the pubic arch. The paraurethral ducts open either on the posterior wall of the urethral orifice or directly into the vestibule.
(b) Vaginal orifice and hymen: The vaginal orifice lies in the posterior end of the vestibule and is of varying size and shape. In virgins and nulliparae, the opening is closed by the labia minora, but in parous, it may be exposed. It is incompletely closed by a septum of mucous membrane, called hymen. The membrane varies in shape but is usually circular or crescentic in virgins. The hymen is usually ruptured at the consummation of marriage. During childbirth, the hymen is extremely lacerated and is later represented by cicatrized nodules of varying size, called the carunculae myrtiformes. On both sides it is lined by stratified squamous epithelium.
(c) Opening of Bartholin's ducts: There are two Bartholin glands (greater vestibular gland), one on each side. They are situated in the superficial perinea} pouch, close to the posterior end of the vestibular bulb. They are pea-sized and yellowish white in color. During sexual excitement, it secretes abundant alkaline mucus which helps in lubrication. The glands are of compound racemose variety and are lined by cuboidal epithelium. Each gland has got a duct which measures about 2 cm and opens into the vestibule outside the hymen at the junction of the anterior two-thirds and posterior one-third in the groove between the hymen and the labium minus. The duct is lined by columnar epithelium but near its opening by stratified squamous epithelium. Bartholin's glands are homologous to the bulb of the penis in male.
(d) Slcene's glands are the largest paraurethral glands. Skene's glands are homologous to the prostate in the male. The two Skene's ducts may open in the vestibule on either side of the external urethral meatus.
VESTIBULAR BULB: These are bilateral elongated masses of erectile tissues situated beneath the mucous membrane of the vestibule. Each bulb lies on either side of the vaginal orifice in front of the Bartholin's gland and is incorporated with the bulbocavernosus muscle. They are homologous to the bulb of the penis
Chapter 1: Anatomy of Female Reproductive Organs
Urethral meatus Clitoris
Bulbocavernosus
Bulb of vestibule Labium minus
lschiocavernosus
Greater vestibular (Bartholin's gland)
Levator ani
Anus
Fig. 1.2: Exposition of superficial perinea! pouch with vestibular bulb and Bartholin's gland.
and corpus spongiosum in the male. They are likely to be injured during childbirth with brisk hemorrhage (Fig.1.2).
II PERINEUM
The details of its anatomy are described later in the chapter.
BLOOD SUPPLY: Arteries: (a) Branches of internal puden­ da! artery-the chief being labial, transverse perineal, artery to the vestibular bulb and deep and dorsal arteries to the clitoris. (b) Branches of femoral artery-superficial and deep external pudenda!.
Veins: The veins form plexuses and drain into­ (a) internal pudendal vein, (b) vesical or vaginal venous plexus and (c) long saphenous vein. Varicosities during pregnancy are not uncommon and may rupture spontaneously causing visible bleeding or hematoma formation.
NERVE SUPPLY: The supply is through bilateral spinal somatic nerves-anterosuperior part is supplied by the cutaneous branches from the ilioinguinal and genital
branch of genitofemoral nerve (L1 and L2) and the posteroinferior part by the pudenda! branches from
the posterior cutaneous nerve of thigh (S1,2,3). Between these two groups, the vulva is supplied by the labial and
perinea! branches of the pudenda! nerve (S2,3,4). LYMPHATICS: Vulval lymphatics have bilateral drainage. Lymphatics drain into-(a) superficial inguinal nodes, (b) intermediate groups of inguinal lymph nodes-gland of Cloquet and (c) external and internal iliac lymph nodes.
DEVELOPMENT: External genitalia is developed in the region of the cranial aspect of ectodermal cloacal fossa; clitoris from the genital tubercle; labia minora from the genital folds; labia majora from the labioscrotal swelling and the vestibule from the urogenital sinus.
INTERNAL GENITALIA
The internal genital organs in female include vagina, uterus, Fallopian tubes and the ovaries. These organs are placed internally and require special instruments for inspection.
I VAGINA
The vagina is a fibromusculomembranous sheath communicating the uterine cavity with the exterior at the vulva. It constitutes the excretory channel for the uterine secretion and menstrual blood. It is the organ of copulation and forms the birth canal of parturition. The canal is directed upwards and backwards forming an angle of 45° with the horizontal in erect posture. The long axis of the vagina almost lies parallel to the plane of the pelvic inlet and at right angles to that of the uterus. The diameter of the canal is about 2.5 cm, being widest in the upper part and narrowest at its introitus. It has got enough power of distensibility as evident during childbirth.
WALLS: Vagina has got an anterior, a posterior and two lateral walls. The anterior and posterior walls are opposed together but the lateral walls are comparatively stiffer especially at its middle, as such, it looks 'H' shaped on transverse section. The length of the anterior wall is about 7 cm and that of the posterior wall is about 9 cm.
.. Chapter 1: Anatomy of Female Reproductive Organs
FORNICES: The fornices are the clefts formed at the top of vagina (vault) due to the projection of the uterine cervix through the anterior vaginal wall where it is blended inseparably with its wall. There are four fornices-one anterior, one posterior and two lateral; the posterior one being deeper and the anterior, most shallow one.
RELATIONS
Anterior: The upper one-third is related with base of the bladder and the lower two-thirds are with the urethra, the lower half of which is firmly embedded with its wall.
Posterior: The upper one-third is related with the pouch of Douglas, the middle-third with the anterior rectal wall separated by rectovaginal septum and the lower-third is separated from the anal canal by the perineal body (Fig. 1.3).
Lateral walls: The upper one-third is related with the pelvic cellular tissue at the base of broad ligament in which the ureter and the uterine arte1y lie approximately 2 cm from the lateral fornices. The middle-third is blended with the levator ani and the lower-third is related with the bulbocavernosus muscles, vestibular bulbs and Bartholin's glands (Fig. 1.11).
STRUCTURES: Layers from within outwards are-(1) mucous coat which is lined by stratified squamous epithelium without any secreting glands, (2) submucous layer of loose areolar vascular tissues, (3) muscular layer consisting of indistinct inner circular and outer longitudinal muscles and (4) fibrous coat derived from the endopelvic fascia and is highly vascular.
VAGINAL SECRETION: The vaginal pH, from puberty to menopause, is acidic because of the presence of Doderlein's bacilli which produce lactic acid from the glycogen present in the exfoliated cells. The pH varies with the estrogenic activity and ranges between 4 and 5.
Peritoneum
Fallopian tube
Uterovesical pouch
Bladder
BLOOD SUPPLY: The arteries involved are-(1) cervico­ vaginal branch of the uterine artery, (2) vaginal arte1y-a branch of anterior division of internal iliac or in common origin with the uterine, (3) middle rectal and (4) internal pudendal. These anastomose with one another and form two azygos arteries-anterior and posterior.
Veins drain into internal iliac veins and internal pudendal veins.
LYMPHATICS: On each side, the lymphatics drain into-(1) upper one-third-internal iliac group, (2) middle one­ third up to hymen-internal iliac group, (3) below the hymen-superficial inguinal group.
NERVE SUPPLY: The vagina is supplied by sympathetic and parasympathetic from the pelvic plexus. The lower part is supplied by the pudendal nerve.
DEVELOPMENT: The vagina is developed from the following sources: (a) Upper four-fifths, above the hymen-the mucous membrane is derived from endoderm of the canalized sinovaginal bulbs. The musculature is developed from the mesoderm of two fused Miillerian ducts. (b) Lower one-fifth, below the hymen is developed from the endoderm of the urogenital sinus. ( c) External vaginal orifice is formed from the genital fold ectoderm after rupture of the urogenital membrane.
I UTERUS
The uterus is a hollow pyriform muscular organ situated in the pelvis between the bladder in front and the rectum behind.
POSITION: Its normal position is one of the anteversion and anteflexion. The uterus usually inclines to the right ( dextrorotation) so that the cervix is directed to the left (levorotation) and comes in close relation with the left ureter.
------- Sacrum
---"- - - Ovary
-
\ ,
-
;-- ""< - Uterus
,
-----""j>-Pouch of Douglas "-¥-- - - =-- Rectum
-
)
\
t
-
Perinea! body
Vagina - ---'_,--- - - -'
Fig. 1.3: Midsagittal section of the female pelvis showing relative position of the pelvic organs.
Chapter 1: Anatomy of Female Reproductive Organs ..
MEASUREMENTS AND PARTS: The uterus measures about 8 cm long, 5 cm wide at the fundus and its walls are about 1.25 cm thick. Its weight varies from 50 to 80 g. It has got the following parts:
♦ Body or corpus ♦ Isthmus ♦ Cervix
(1) Body or corpus: The body is further divided into fundus-the part which lies above the openings of the uterine tubes. The body proper is triangular and lies between the openings of the tubes and the isthmus. The superolateral angles of the body of the uterus project outwards from the junction of the fundus and body and is called the cornua of the uterus. The uterine tube, round ligament and ligament of the ovary are attached to it. (2) Isthmus is a constricted part measuring about 0.5 cm, situated between the body and the cervix. It is limited above by the anatomical internal os and below by the histological internal os (Aschoff). Some consider isthmus as a part of the lower portion of the body of the uterus. (3) Cervix is cylindrical in shape and measures about 2.5 cm. It extends from the isthmus and ends at the external os which opens into the vagina after perforating its anterior wall. The part lying above the vagina is called supravaginal and that which lies within the vagina is
called the vaginal part (Fig. 1.4).
CAVITY: The cavity of the uterine body is triangular on coronal section with the base above and the apex below. It measures about 3.5 cm. There is no cavity in the fundus. The cervical canal is fusiform and measures about 2.5 cm. Thus, the normal length of the uterine cavity is usually 6.5-7cm.
RELATIONS
Anteriorly: Above the internal os, the body forms the posterior wall of the uterovesical pouch. Below the internal os, it is separated from the base of the bladder by loose areolar tissue.
Posteriorly: It is covered with peritoneum and forms the anterior wall of the pouch of Douglas containing coils of intestine.
Laterally: The double fold of peritoneum of the broad ligament are attached between which the uterine artery ascends up. Attachment of the Mackenrodt's ligament extends from the internal os down to the supravaginal cervix and lateral vaginal wall. About 1.5 cm away at the level of internal os, a little nearer on the left side is the crossing of the uterine arte1y and the ureter. The uterine artery crosses from above and in front of the ureter, soon before the ureter enters the ureteric tunnel (Fig. 1.5).
STRUCTURES
Body: The wall consists of three layers from outside inwards:
l. Parametrium: It is the serous coat which invests the entire organ except on the lateral borders. The peritoneum is intimately adherent to the underlying muscles.
2. Myometrium: It consists of thick bundles of smooth muscle fibers held by connective tissues and are arranged in various directions. During pregnancy, however, three distinct layers can be identified-outer longitudinal, middle interlacing and the inner circular.
3. Endometrium: The mucus lining of the cavity is called endometrium. As there is no submucous layer, the endometrium is directly opposed to the muscle coat. It consists of lamina propria and surface epithelium. The surface epithelium is a single layer of ciliated columnar epithelium. The lamina propria contains stromal cells, endometrial glands, vessels and nerves. The glands are simple tubular and lined by mucus secreting non-ciliated columnar epithelium which penetrate the stroma and sometimes even enter the muscle coat. The endometrium is changed to decidua during pregnancy.
Anatomical internal os
lsthmu (0.5 cm
Cervix (2 5 cm)
_
--
-·
-
A , J
i.-----\ \
---Histological internal os
Supravaginal portion
Portia vaginalis
External os
Azygos-----f arteries to
the vagina
- - Descending
cervical branch
Fig. 1.4: Coronal section showing different parts of uterus. Fig. 1.5: The relation of the ureter to the uterine artery.
Chapter 1: Anatomy of Female Reproductive Organs
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Cervix-The cervix is composed mainly of fibrous con­ nective tissues. The smooth muscle fibers average 10-15%. Only the posterior surface has got peritoneal coat. Mucous coat lining the endocervix is simple columnar with basal nuclei and that lining the gland is non-ciliated secretory columnar cells. The vaginal part of the cervix is lined by stratified squamous epithelium. The squamocolumnar junction is situated at the external os.
SECRETION: The endometrial secretion is scanty and watery. Secretion of the cervical glands is alkaline and thick, rich in mucoprotein, fructose and sodium chloride.
PERITONEUM IN RELATION TO THE UTERUS: Traced anteriorly: The peritoneum covering the superior sur­ face of the bladder reflects over the anterior surface of the uterus at the level of the internal os. The pouch, so formed, is called uterovesical pouch. The peritoneum thereafter, is firmly attached to the anterior and post­ erior walls of the uterus and upper one-third of the posterior vaginal wall from where it is reflected over the rectum. The pouch, so formed, is called pouch of Douglas {Fig. 1.3).
Traced laterally: The adherent peritoneum of the anterior and posterior walls of the uterus is continuous laterally forming the broad ligament. Laterally, it extends to the lateral pelvic walls where the layers reflect to cover the anterior and posterior aspects of the pelvic cavity. On its superior free border, lies the Fallopian tube and on the posterior layer, the ovary is attached by mesovarium. The lateral one-fourth of the free border is called infundibulopelvic ligament.
BLOOD SUPPLY: Arterial supply: The blood supply is from the uterine arteries one on each side. The artery arises directly from the anterior division of the internal iliac or in common with superior vesical artery. The other sources are ovarian and vaginal arteries with which the uterine arteries anastomose. The internal supply of the uterus is shown in Figures 1.6A and B.
Arcuate artery
Veins: The venous channels correspond to the arterial course and drain into internal iliac veins.
LYMPHATICS: Body: (1) From the fundus and upper part of the body of the uterus, the lymphatics drain into preaortic and lateral aortic groups of glands. (2) Cornu drains to superficial inguinal gland along the round ligament. (3) Lower part of the body drains into external iliac groups.
Cervix: On each side, the lymphatics drain into­ (1) external iliac, obturator lymph nodes either directly or through paracervical lymph nodes, (2) internal iliac groups and (3) sacral groups.
NERVES: The nerve supply of the uterus is derived principally from the sympathetic system and partly from the parasympathetic system. Sympathetic components
are from T5 to T6 (motor) and T10 to L1 spinal segments (sensory). The somatic distribution of uterine pain is
that area of the abdomen supplied by T 10 to L8. The parasympathetic system is represented on either side by
the pelvic nerve which consists of both motor and sensory
fibers from S2,3,4 and ends in the ganglia of Frankenhauser.
The details are described in Ch. 34.
The cervix is insensitive to touch, heat and also
when it is grasped by any instrument. The uterus, too, is insensitive to handling and even to incision over its wall.
DEVELOPMENT: The uterus is developed from the fused vertical part of the two Miillerian ducts.
I FALLOPIAN TUBE (Synonyms: Uterine tube, oviduct)
The uterine tubes are paired structures, measuring about 10 cm and are situated in the medial three-fourths of the upper free margin of the broad ligament. Each tube has got two openings, one communicating with the lateral angle of the uterine cavity called uterine opening and measures 1 mm in diameter, the other is on the lateral end of the tube, called pelvic opening or abdominal ostium and measures about 2 mm in diameter.
Endometrium
Basal artery \ Spiral artery UI
Capillary plexus
'I
Venous lake
Spiral artery
Radial artery Myometrium
Perimetnum
Gland Basal artery
Uterine artery Uterine vein
rn
Figs. 1.6A and B: (A) Showing pattern of basal and spiral arteries in the endometrium; (B) Internal blood supply of uterus.
Chapter 1: Anatomy of Female Reproductive Organs ..
PARTS: There are four parts. From medial to lateral are­ (1) intramural or interstitial lying in the uterine wall and measures 1.25 cm in length and 1 mm in diameter, (2) isthmus-almost straight and measures about 3-4 cm in length and 2 mm in diameter, (3) ampulla-tortuous part and measures about 5 cm in length which ends in, (4) wide infundibulum measuring about 1.25 cm long with a maximum diameter of6 mm. The abdominal ostium is surrounded by a number of radiating fimbriae (20-25), one of these is longer than the rest and is attached to the outer pole of the ovary called ovarian fimbria (Fig. I. 7).
STRUCTURES: It consists of three layers-(1) Serous: consists of peritoneum on all sides except along the line of attachment of mesosalpinx, (2) Muscular: arranged in two layers outer longitudinal and inner circular and (3) Mucous membrane has three different cell types and is thrown into longitudinal folds. The epithelium rests on a delicate vascular reticulum of connective tissue. Mucous membrane is lined by: (i) Columnar ciliated epithelial cells that are most predominant near the ovarian end of the tube. These cells compose 25% of the mucosa! cells, (ii) Secretory columnar cells are present at the isthmic segment and compose 60% of epithelial cells, (iii) Peg cells are found in between the above two cells. They are
the variant of secretory cells.
FUNCTIONS: The important functions of the tubes are-(1) transport of the gametes and (2) to facilitate fertilization and survival of zygote through its secretion.
BLOOD SUPPLY: Arterial supply is from the uterine and ovarian. Venous drainage is through the pampiniform plexus into the ovarian veins.
LYMPHATICS: The lymphatics run along the ovarian vessels to para-aortic nodes.