DC Dutta's Textbook of Obstetrics

1 Anatomy of Female Reproductive Organs 1
 External Genitalia 1; Mons Veneris (Mons Pubis) 1; Labia Majora 2; Labia Minora 2;
Clitoris 2; Vestibule 2; Perineum 2;  Internal Genitalia 3; Vagina 3; Uterus 4;
Fallopian Tube 6; Ovary 7;  Muscles and Fascia in Relation to the Pelvic Organs 9; Pelvic
Floor 9; Perineum 10; Pelvic Fascia 11;  Pelvic Cellular Tissue 11;  Female Urethra 12;
 Urinary Bladder 12;  Pelvic Ureter 12;  Breasts 13
2 Fundamentals of Reproduction 15
BN Chakravorty
 Gametogenesis 15; Oogenesis 15; Spermatogenesis 17;  Ovulation 17;  Fertilization 18;
Morula 19; Blastocyst 19;  Implantation 20; Trophoblast 21;  Decidua 21;  Chorion and
Chorionic Villi 22;  Development of Inner Cell Mass 22
3 Placenta and Fetal Membranes 25
 Placenta 25; Development 25; Placenta at Term 26; Structures 26;  Placental Circulation 28;
 Placental Aging 31;  Placental Function 31;  Fetal Membranes 33;  Amniotic Cavity and
Amnion 33;  Amniotic Fluid 34;  Umbilical Cord 35
4 The Fetus 37
 Fetal Physiology 38;  Fetal Circulation 39; Changes of the Fetal Circulation at Birth 40
5 Physiological Changes during Pregnancy 42
 Genital Organs 42; Uterus 42;  Breasts 45;  Cutaneous Changes 45;  Weight Gain 46;
 Body Water Metabolism 46;  Hematological Changes 46;  Cardiovascular System 48;
 Metabolic Changes 49;  Systemic Changes 50
6 Endocrinology in Relation to Reproduction 53
BN Chakravorty
 Maturation of Graafian Follicles and Ovulation 53;  Maintenance of Corpus Luteum after
Fertilization 53;  Placental Endocrinology 53; Hormones of Placenta 53; Protein Hormones 53;
Steroidal Hormones 55; Diagnostic Value of Placental Hormones 56;  Changes of Endocrine Glands
during Pregnancy 56; Pituitary Gland 56; Thyroid Gland 57; Adrenal Cortex 57; Parathyroid
Gland 57; Pancreas 58;  Hormonal Influences Necessary for Maintenance of Lactation 58
7 Diagnosis of Pregnancy 60
 First Trimester (First 12 Weeks) 60;  Second Trimester (13–28 Weeks) 63;  Last Trimester
(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 68
xvi Textbook of Obstetrics
8 The Fetus-in-Utero 69
 Causes of Preponderance of Longitudinal Lie and Cephalic Presentation 71;  Methods of Obstetrical
Examination 71
9 Fetal Skull and Maternal Pelvis 76
 Fetal Skull 76;  Pelvis 79; False Pelvis 79; True Pelvis 79; Inlet 80; Cavity 82; Outlet 82;
Midpelvis 83; Physiological Enlargement of Pelvis during Pregnancy and Labor 85
10 Antenatal Care, Preconceptional Counseling and Care 86
 Procedure at the First Visit 86; History Taking 86; Examination 88;  Procedure at the Subsequent
Visits 89;  Antenatal Advice 90;  Minor Ailments in Pregnancy 92;  Values of Antenatal Care 93;
 Preconceptional Counseling and Care 94
11 Antenatal Assessment of Fetal Wellbeing 96
 Clinical Evaluation of Fetal Wellbeing at Antenatal Clinic 96; First Visit 96; Subsequent
Visits 96; Special Investigations 97; Early Pregnancy 97;  Antepartum Fetal Surveillance
(Late Pregnancy) 97;  Other Investigations in Late Pregnancy 100
12 Prenatal Genetic Counseling, Screening and Diagnosis 102
 Prenatal Genetic Screening 102; Prenatal Diagnosis 103;  Invasive Procedures for Prenatal
Diagnosis 104; Chorionic Villus Sampling (CVS) 104; Amniocentesis 105; Cordocentesis or
Percutaneous Umbilical Blood Sampling (PUBS) 105;  Noninvasive Method of Prenatal Testing from
Maternal Plasma/Blood 106; Fetal DNA 106
13 Normal Labor 108
Sir Sabaratnam Arulkumaran
 Causes of Onset of Labor 108; Contractile System of the Myometrium 110;  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 121;  Clinical Course of First Stage of Labor 121;  Clinical Course of Second Stage of
Labor 123;  Clinical Course of Third 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 128; Immediate Care of the Newborn 130;  Management of Third Stage of Labor 132;
Active Management of Third Stage of Labor (AMTSL) 134
14 Normal Puerperium 137
 Involution of the Uterus 137;  Involution of Other Pelvic Structures 138; Lochia 138;
 General Physiological Changes 139;  Lactation 140; Physiology of Lactation 140;
 Management of Normal Puerperium 142;  Management of Ailments 143;  Postnatal Care 145
15 Vomiting in Pregnancy 147
 Vomiting in Pregnancy 147;  Hyperemesis Gravidarum 147; Clinical Course 148; Management 149
16 Hemorrhage in Early Pregnancy 151
 Spontaneous Abortion (Miscarriage) 151; Etiology 151;  Threatened Miscarriage 153;
 Inevitable Miscarriage 154;  Complete Miscarriage 155;  Incomplete Miscarriage 155;
 Missed Miscarriage 155;  Septic Abortion 156; Management 158;  Recurrent Miscarriage 159;
Etiology 159; Cervical Incompetence (Cervical Insufficiency) 161; Investigations for Recurrent
Miscarriage 161; Treatment 161; Management of Cervical Incompetence 162; Prognosis of
Recurrent Miscarriage 164;  Induction of Abortion 164;  Medical Termination of Pregnancy
Contents xvii
(MTP) 164; Recommendations 165; Methods of Termination of Pregnancy 165; First
Trimester Termination of Pregnancy (up to 12 Weeks) 165; Midtrimester Termination of
Pregnancy 166; Complications of MTP 167;  Ectopic Pregnancy 168; Tubal Pregnancy 168;
Morbid Anatomy 169; Mode of Termination 170; Clinical Features of Ectopic Pregnancy 171;
Acute Ectopic Pregnancy 171; Unruptured Tubal Ectopic Pregnancy 171; Chronic or Old Ectopic
Pregnancy 172; Diagnosis of Ectopic Pregnancy 172;  Management of Ectopic Pregnancy 173;
 Management of Unruptured Tubal Pregnancy 174;  Interstitial Pregnancy 176;
 Abdominal Pregnancy 177;  Ovarian Pregnancy 177;  Cornual Pregnancy 178;
 Cervical Pregnancy 178;  Pregnancy of Unknown Location 178;  Cesarean Scar Pregnancy 179;
 Heterotopic Pregnancy 179;  Gestational Trophoblastic Diseases (GTD) 180; Hydatidiform
Mole 180; Pathology of Hydatidiform Mole 181; Clinical Features 181; Complications of Molar
Pregnancy 183; Management 183;  Partial or Incomplete Mole 186;  Placental Site Trophoblastic
Tumor (PSTT) 187;  Persistent Gestational Trophoblastic Disease 187
17 Multiple Pregnancy, Amniotic Fluid Disorders, Abnorma
xviii Textbook of Obstetrics
Pregnancy 276;  Parasitic and Protozoal Infestations in Pregnancy 277;  Pyelonephritis in
Pregnancy 279; Asymptomatic Bacteriuria (ASB) 279;  Viral Infections in Pregnancy 280;
Human Immunodeficiency Virus (HIV) Infection and Acquired Immunodeficiency Syndrome (AIDS) 282;
Management 283;  Surgical Illness during Pregnancy 284;  Acute Pain in Abdomen during
Pregnancy 285
21 Gynecological Disorders in Pregnancy 287
 Abnormal Vaginal Discharge 287;  Congenital Malformation of the Uterus and
Vagina 287;  Carcinoma Cervix with Pregnancy 288; Treatment 288;  Leiomyomas with
Pregnancy 288; Treatment 290;  Ovarian Tumor in Pregnancy 290;  Retroverted Gravid
Uterus 291; Morbid Anatomic Changes if Left Uncared for 291; Treatment 292;
 Genital Prolapse in Pregnancy 292; Treatment 293
22 Preterm Labor and Birth, Preterm Rupture of the Membranes, Postmaturity, Intrauterine Fetal Death 294
 Preterm Labor and Birth 294; Etiology 294; Management of Preterm Labor and Birth 294;
Prevention of Preterm Labor 295; Measures to Arrest Preterm Labor 295;  Management in
Labor 296;  Prelabor Rupture of the Membranes (PROM) 297; Management 298;  Prolonged and
Post-term Pregnancy 299; Diagnosis 299; Management 301;  Intrauterine Fetal Death (IUFD) 302;
Etiology 302; Diagnosis 303; Recommended Evaluation for a Stillbirth 304; Management 304
23 Complicated Pregnancy 307
 Pregnancy with Prior Cesarean Delivery 307; Sound Scar: Lower Segment or Classical? 307;
Evidences of Scar Rupture (or Scar Dehiscence) during Labor 308; Management of a Pregnancy
with Prior Cesarean Delivery 309; Vaginal Birth after Previous Cesarean (VBAC) Delivery 309;
 Red Cell Alloimmunization 311; Fetal Affection by the Rh Antibody 313;  Manifestations
of the Hemolytic Disease of the Fetus and Newborn (HDFN) 313; Prevention of Rh-D
Alloimmunization 314;  Antenatal Investigation Protocol of Rh-negative Mothers 315;
 Plan of Delivery 317;  Exchange Transfusion in the Newborn 319; Prognosis 320;
 Elderly Primigravida 320;  Grand Multipara 321;  Bad Obstetric History (BOH) 321;
Investigations and Management 321;  Obesity in Pregnancy 322
24 Contracted Pelvis 324
 Asymmetrical or Obliquely Contracted Pelvis 326;  Mechanism of Labor in Contracted Pelvis with
Vertex Presentation 326;  Diagnosis of Contracted Pelvis 327;  Disproportion 330; Diagnosis
of Cephalopelvic Disproportion (CPD) at the Brim 330;  Effects of Contracted Pelvis on Pregnancy
and Labor 332;  Management of Contracted Pelvis (Inlet Contraction) 332;  Trial Labor 332;
 Midpelvic and Outlet Disproportion 333
25 Abnormal Uterine Action 335
 Uterine Inertia (Hypotonic Uterine Dysfunction) 336;  Incoordinate Uterine Action 337;
 Precipitate Labor 339;  Tonic Uterine Contraction and Retraction 339
26 Complicated Labor: Malposition, Malpresentation and Cord Prolapse 343
 Occiput Posterior (OP) Position 343; Diagnosis 344; Mechanism of Labor 345;
Course of Labor 346; Management of Labor 348; Arrested Occipitoposterior Position 348;
 Deep Transverse Arrest (DTA) 349;  Manual Rotation for Occipitoposterior Position 349;
 Breech Presentation 351; Varieties 351; Etiology of Breech Presentation 352; Diagnosis
of Breech Presentation 352; Mechanism of Labor in Breech Presentation 353; Complications
of Vaginal Breech Delivery 355; Antenatal Management 356; Management of Vaginal Breech
Delivery 357; Assisted Breech Delivery 357; Management of Complicated Breech Delivery 361;
 Face Presentation 364; Mechanism of Labor 364; Diagnosis 365; Management 367;
Vaginal Delivery 367;  Brow Presentation 367;  Transverse Lie 368; Diagnosis 369;
Contents xix
Clinical Course of Labor 370;  Management of Shoulder Presentation 371;  Unstable Lie 372;
 Compound Presentation 372;  Cord Prolapse 373; Management 374
27 Prolonged Labor, Obstructed Labor, Dystocia Caused by Fetal Anomalies 376
 Prolonged Labor 376; Treatment 377;  Obstructed Labor 379; Treatment 380;
 Dystocia caused by Fetal Anomalies 380; Shoulder Dystocia 380; Hydrocephalus 381;
 Neural Tube Defects (NTD) 383; Anencephaly 383;  Conjoined Twins 383
28 Complications of the Third Stage of Labor 385
 Postpartum Hemorrhage (PPH) 385;  Primary Postpartum Hemorrhage 385; Causes 385;
Prevention 386; Management of Third-stage Bleeding 387; Steps of Manual Removal of
Placenta 387; Management of True Postpartum Hemorrhage 389; Actual Management 389;
 Secondary Postpartum Hemorrhage 392;  Retained Placenta 393; Management 394;
Management of Unforeseen Complications during Manual Removal of Placenta 394;
 Placenta Accreta 394;  Inversion of the Uterus 395
29 Injuries to the Birth Canal 397
 Vulva 397;  Perineum 397; Management 397;  Vagina 398;  Cervix 398;
 Pelvic Hematoma 399;  Rupture of the Uterus 400; Etiology 400; Pathology 402; Diagnosis 402;
Management 404;  Visceral Injuries 404
30 Abnormalities of the Puerperium 406
 Puerperal Pyrexia 406;  Puerperal Sepsis 406; Pathology 407; Pathogenesis 407; Clinical
Features 407; Investigations of Puerperal Pyrexia 408; Prophylaxis 408; Treatment 409;
 Subinvolution 410;  Urinary Complications in Puerperium 410;  Breast Complications 410;
Breast Engorgement 410; Cracked and Retracted Nipple 411; Acute Mastitis 411;  Puerperal Venous
Thrombosis and Pulmonary Embolism 412; Prophylaxis and Management for Venous Thromboembolism
(VTE) in Pregnancy and Puerperium 413; Pulmonary Embolism (PE) 414;  Obstetric Palsies 414;
 Puerperal Emergencies 414;  Psychiatric Disorders during Puerperium 415;  Psychological
Response to Perinatal Deaths and Management 415
31 The Term Newborn Infant 417
S Banerjee
 Physical Features of the Newborn 417;  Immediate Care of the Newborn 419;  Infant Feeding 420;
Breastfeeding 421; Artificial Feeding 425; Childhood Immunization Program 426
32 Low Birth Weight Baby 427
S Banerjee
 Preterm Baby 427; Complications of a Preterm Neonate 428; Management 429;
Care of a Preterm Neonate 429;  Fetal Growth Restriction (FGR) 431; Management 434
33 Diseases of the Fetus and the Newborn 438
S Banerjee
 Perinatal Asphyxia 438; Fetal Respiration 438; Clinical Features 439; Management 440;
 Respiratory Distress in the Newborn 443; Idiopathic Respiratory Distress Syndrome 443;
 Transient Tachypnea of the Newborn (TTN) 445; Meconium Aspiration Syndrome (MAS) 446;
 Jaundice of the Newborn 446; Causes of Neonatal Jaundice 446; Hyperbilirubinemia of the
Newborn 447; Kernicterus 448; Management of Jaundice in the Newborn 448;  Hemolytic
Disease of the Newborn (HDN) 449; ABO Group Incompatibility 449;  Bleeding Disorders in the
Newborn 450;  Anemia in the Newborn 450;  Seizures in the Newborn 451;  Birth Injuries
xx Textbook of Obstetrics
of the Newborn 451; Injuries to the Head 452; Intracranial Hemorrhage (ICH) 453; Other
Injuries 454;  Perinatal Infections 455; Mode of Infection 456; Ophthalmia Neonatorum
(Conjunctivitis) 457; Skin Infections 457; Necrotizing Enterocolitis 458; Mucocutaneous
Candidiasis 458;  Congenital Malformations and Prenatal Diagnosis 459; Down’s Syndrome
(Trisomy 21) 460;  Congenital Malformations in Newborn and the Surgical Emergencies 460;
 Nonimmune Fetal Hydrops (NIFH) 462
34 Pharmacotherapeutics in Obstetrics 464
 Oxytocics in Obstetrics 464; Oxytocin 464; Dangers of Oxytocin 465; Methods of Administration
of Oxytocin 465; Diagnostic Use of Oxytocin 466; Ergot Derivatives 467; Prostaglandins (PGS) 467;
 Antihypertensive Therapy 470;  Diuretics 470;  Tocolytic Agents 471;  Anticonvulsants 472;
 Anticoagulants 473;  Maternal Drug Intake and Breastfeeding 474;  Fetal Hazards on Maternal
Medication during Pregnancy 474; Teratology and Prescribing in Pregnancy 474;  Analgesia and
Anesthesia in Obstetrics (BB Hore) 477; Anatomical and Physiological Considerations 477; Analgesia
during Labor and Delivery 478; Sedatives and Analgesics 478; Inhalation Methods 479; Regional
(Neuraxial) Anesthesia 479; Infiltration Analgesia 481; General Anesthesia for Cesarean Section 482
35 Induction of Labor 484
 Methods of Induction of Labor 485; Medical Induction 485; Surgical Induction 487;
Low Rupture of the Membranes (LRM) 488; Stripping the Membranes 489;
 Combined Method 489;  Active Management of Labor 490;  Partograph 491
36 Population Dynamics and Control of Conception 494
 Population Dynamics 494;  Control of Conception 494; Family Planning 494; Contraception 495;
 Methods of Contraceptions 495; Temporary Methods 496; Intrauterine Contraceptive Devices
(IUCDs) 496; Steroidal Contraceptions 503; Combined Oral Contraceptives (Pills) 503;
Centchroman (Chhaya) 508; Progestogen-only Contraceptions 508; Emergency Contraception
(EC) 509; Summary of Oral Contraceptives 510;  Sterilization 511; Couple Counseling 511;
Male Sterilization 511; Female Sterilization 513;  Barrier Methods 517; Condom (Male) 517;
Female Condom (Femidom) 517; Diaphragm 518; Vaginal Contraceptives 519; Fertility Awareness
Method 519; Contraceptive Counseling and Prescription 520; Sterilization Counseling 520;
Prescription 520;  Ongoing Trials and Selective Availability 521; Transcervical Sterilization 522;
Male Contraception Methods 522
37 Operative Obstetrics 524
 Dilatation and Evacuation (D & E) 524; One-stage Operation 524; Two-stage
Operation 525; Management Protocol of Uterine Perforation 526;
 Suction Evacuation 526;  Menstrual Regulation 527;  Vacuum Aspiration 527;
 Hysterotomy 527;  Episiotomy 528; Types 528; Steps of Mediolateral Episiotomy 529;
Postoperative Care 530; Complications of Episiotomy 531;  Operative Vaginal
Delivery 531; Forceps 531; Long-curved Obstetric Forceps 531; Short-curved Obstetric
Forceps (Wrigley) 532; Kielland’s Forceps 532; Choice of Forceps Operation 532; Lowforceps Operation 533; Outlet Forceps Operation 536; Midforceps Operation 536; Difficulties
in Forceps Operation 536; Kielland’s Forceps 537; Complications of Forceps
Operation 537;  Ventouse 538;  Version 541; External Cephalic Version 541; Internal
Version 542;  Destructive Operations 543; Craniotomy 543; Decapitation 545;
Evisceration 545; Cleidotomy 545; Postoperative Care Following Destructive Operations 545;
 Cesarean Section (CS) 545; Indications 546; Lower Segment Cesarean Section
(LSCS) 547; Postoperative Care 550; Classical Cesarean Section 551; Complications of
Cesarean Section 551; Intraoperative Complications 552; Postoperative Complications 553;
 Symphysiotomy 554  BD Odon Device 554
Contents xxi
38 Safe Motherhood, Epidemiology of Obstetrics 556
 Safe Motherhood 556;  Reproductive and Child Health (RCH) Care 557; RCH Interventions 557;
 Epidemiology of Obstetrics 558; Maternal Mortality 558; Maternal Near Miss 561;
Maternal Morbidity 561; Perinatal Mortality 561; Important Causes of Perinatal Mortality and
Main Interventions 562; Stillbirths 563; Neonatal Deaths 563;  Sustainable Development
Goals (SDGs) 564
39 Special Topics in Obstetrics 566
 Intrapartum Fetal Monitoring (Sir Sabaratnam Arulkumaran) 566; Methods of Fetal
Monitoring 566;  Nonreassuring Fetal Status (NRFS) 570; Management of Nonreassuring
Fetal Status (NRFS) 571;  Shock in Obstetrics (BN Chakravorty) 572; Pathophysiology of
Shock 572; General Changes in Shock 573; Changes in Endotoxic Shock 575; Classification
of Shock 575;  Management of Shock 576; Hemorrhagic Shock 576; Endotoxic Shock 577;
 Acute Kidney Injury (AKI) 579; Causes of Acute Kidney Injury (AKI) 579; Management of AKI
in Obstetrics (M Kataruka) 580;  Blood Coagulation Disorders in Obstetrics 582; Normal Blood
Coagulation 582; Physiological Changes in Pregnancy 583; Pathological Conditions of Acquired
Coagulopathy 584; Mechanism of Acquired Coagulopathy 584; Investigations 585; Treatment 586;
 High-risk Pregnancy (KM Gun) 587; Screening of High-risk Cases 587; Initial Screening 587;
Management of High-risk Cases 589;  Immunology in Obstetrics 590;  Critical Care in
Obstetrics 592; Objective Parameters (Selected) for Admission of a Patient (Nonpregnant) in an ICU 593
40 Current Topics in Obstetrics 595
 Antibiotic Prophylaxis in Cesarean Section 595;  Day-care Obstetrics 595;  Legal and Ethical
Issues in Obstetric Practice 596;  Audit in Obstetrics 596;  The Preconception and Prenatal
Diagnostic Techniques 597;  Umbilical Cord Blood Stem Cells in Transplantation and Regenerative
Medicine 597; Stem Cells and Therapies in Obstetrics 598
41 Imaging in Obstetrics (USG, MRI, CT, Radiology), Amniocentesis and Guides to Clinical Tests 599
 Ultrasound in Obstetrics 599; Three-dimensional Ultrasonography (3D Scanning) 600; First
Trimester Ultrasonography 601; Midtrimester Ultrasonography 601; Third Trimester
Ultrasonography 605;  Magnetic Resonance Imaging (MRI) 605;  Computed Tomography (CT)
in Obstetrics 606;  Radiology in Obstetrics 606;  Amniocentesis 607;  Guides to Clinical
Tests 608; Examination of Urine 608;  Tests for Blood Coagulation Disorders 609; Collection of
Blood Sample 610; Samples for Blood Sugar Estimation 611;  Cervical and Vaginal Cytology 611
42 Practical Obstetrics 612
 Obstetric Instruments 612;  Processing of Instruments 624;  Drugs 624;  Specimens 625;
 Imaging Studies (USG Plates) 627
Index 633