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Library of Congress Cataloging-in-Publication Data

Names: Impey, Lawrence, author. | Child, Tim, author.

Title: Obstetrics & gynaecology / Lawrence Impey and Tim Child.

Other titles: Obstetrics and gynaecology

Description: 5th edition. | Chichester, West Sussex : John Wiley & Sons Ltd., 2017. | Includes bibliographical references and index.

Identifiers: LCCN 2016030548| ISBN 9781119010791 (pbk.) | ISBN 9781119010807 (Adobe PDF) | ISBN 9781119010838 (ePub)

Subjects: | MESH: Pregnancy | Genital Diseases, Female | Pregnancy Complications | Outlines

Classification: LCC RG101 | NLM WQ 18.2 | DDC 618.02/02—dc23 LC record available at https://lccn.loc.gov/2016030548

A catalogue record for this book is available from the British Library.

Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books.

Cover image: © Getty Images / John Fedele

CONTENTS

Preface to the fifth edition

Preface to the first edition

Acknowledgements

List of abbreviations

About the companion website

Gynaecology

Chapter 1: The history and examination in gynaecology
1. The gynaecological history
2. The gynaecological examination
Chapter 2: The menstrual cycle and its disorders
1. Physiology
2. Abnormal uterine bleeding (AUB)
3. Heavy menstrual bleeding (HMB)
4. Irregular menstruation and intermenstrual bleeding
5. Absent and infrequent menstrual bleeding (amenorrhoea and oligomenorrhoea)
6. Postcoital bleeding
7. Dysmenorrhoea
8. Precocious puberty
9. Ambiguous development and intersex
10. Premenstrual syndrome
Chapter 3: The uterus and its abnormalities
1. Anatomy and physiology of the uterus
2. Fibroids
3. Adenomyosis
4. Other benign conditions of the uterus
5. Endometrial carcinoma
6. Uterine sarcomas
Chapter 4: The cervix and its disorders
1. Anatomy and function of the cervix
2. Benign conditions of the cervix
3. Premalignant conditions of the cervix: cervical intraepithelial neoplasia
4. Malignant disease of the cervix
Chapter 5: The ovary and its disorders
1. Anatomy and function of the ovaries
2. Ovarian symptoms
3. Disorders of ovarian function
4. Classification of ovarian tumours
5. Ovarian cancer
6. Palliative care
Chapter 6: Disorders of the vulva and vagina
1. Anatomy
2. Vulval symptoms
3. Miscellaneous benign disorders of the vulva and vagina
4. Premalignant disease of the vulva: vulval intraepithelial neoplasia
5. Carcinoma of the vulva
6. Malignancies of the vagina
Chapter 7: Prolapse of the uterus and vagina
1. Anatomy and physiology of the pelvic supports
2. Prolapse
Chapter 8: Disorders of the urinary tract
1. Anatomy and function of the female lower urinary tract system
2. Investigation of the urinary tract
3. Urinary stress incontinence
4. Overactive bladder
5. Other urinary disorders
Chapter 9: Endometriosis and chronic pelvic pain
1. Endometriosis
2. Management
3. Chronic pelvic pain
Chapter 10: Genital tract infections
1. Infections of the vulva and vagina
2. Infections of the uterus and pelvis
3. Vaginal discharge: causes and treatment
Chapter 11: Fertility and subfertility
1. Definitions
2. Disorders of ovulation
3. Male subfertility
4. Disorders of fertilization
5. Assisted conception
Chapter 12: Contraception
1. Hormonal contraception
2. Emergency contraception
3. Barrier contraception
4. Intrauterine contraceptive devices (‘the coil’)
5. Female sterilization
6. Male sterilization
7. Male hormonal contraception
8. Natural contraception
Chapter 13: The menopause and postreproductive health
1. Postmenopausal bleeding
2. Symptoms and consequences of the menopause (Fig. 13.2)
3. Investigations of the menopause
4. Treatment: hormone replacement therapy
5. Other treatments for the menopause
Chapter 14: Disorders of early pregnancy
1. Physiology of early pregnancy
2. Spontaneous miscarriage
3. Recurrent miscarriage
4. Unwanted pregnancy and therapeutic abortion
5. Ectopic pregnancy
6. Hyperemesis gravidarum
7. Gestational trophoblastic disease
Chapter 15: Gynaecological operations
1. Endoscopy and endoscopic surgery
2. Hysterectomy
3. Other common gynaecological problems
4. Precautions in major gynaecological surgery

Obstetrics

Chapter 16: The history and examination in obstetrics
1. The obstetric history
2. The obstetric examination
3. The postnatal history and examination
4. Basic neonatal assessment
Chapter 17: Antenatal care
1. Preconceptual care and counselling
2. The booking visit
3. Routine later pregnancy tests
4. Continuing antenatal care
5. ‘Minor’ conditions of pregnancy
Chapter 18: Congenital abnormalities and their identification
1. Methods of prenatal testing for congenital abnormalities
2. Chromosomal abnormalities
3. Structural abnormalities
4. Single gene disorders
Chapter 19: Infections in pregnancy
1. Viruses
2. Bacteria, parasites and others
Chapter 20: Hypertensive disorders in pregnancy
1. Normal blood pressure changes in pregnancy
2. Classification of hypertensive disorders in pregnancy
3. Pre-eclampsia
4. Pre-existing hypertension in pregnancy
Chapter 21: Other medical disorders in pregnancy
1. Diabetes and gestational diabetes
2. Cardiac disease
3. Respiratory disease
4. Epilepsy
5. Thyroid disease in pregnancy
6. Liver disease
7. Renal disease
8. Thrombophilias and the antiphospholipid syndrome
9. Venous thromboembolic disease
10. Obesity in pregnancy
11. Mental illness in pregnancy
12. ‘Recreational’ drugs in pregnancy
13. Anaemias
14. Influenza
15. Haemoglobinopathies
16. Female genital mutilation (FGM)
Chapter 22: Red blood cell isoimmunization
1. Definition
2. Pathophysiology
3. Prevention: using anti-D
4. Epidemiology
5. Manifestations of Rhesus disease
6. Management of isoimmunization
Chapter 23: Delivery before term
1. Preterm prelabour rupture of the membranes
Chapter 24: Antepartum haemorrhage
1. Placenta praevia
2. Placental abruption
3. Other causes of antepartum haemorrhage
4. Further reading
Chapter 25: Fetal growth, health and surveillance
1. Fetal health and growth: terminology
2. Fetal surveillance
3. Methods of fetal surveillance
4. The small for gestational age fetus and the IUGR fetus
5. Stillbirth
6. The prolonged pregnancy
Chapter 26: Abnormal lie and breech presentation
1. Abnormal (transverse and oblique) lie
2. Breech presentation
Chapter 27: Multiple pregnancy
Chapter 28: Labour 1: Mechanism – anatomy and physiology
1. Mechanical factors of labour
2. Cervical dilatation: the ‘stages’ of labour
Chapter 29: Labour 2: Management
1. General care of the woman in labour
2. Progress in labour: problems and their treatment
3. Care of the fetus
4. Care of the mother
5. Conduct of labour
6. Different approaches to delivery
Chapter 30: Labour 3: Special circumstances
1. Induction of labour
2. Labour/vaginal birth after a previous caesarean section
3. Prelabour, term rupture of the membranes
Chapter 31: Instrumental and operative delivery
1. Forceps or ventouse delivery
2. Caesarean section
Chapter 32: Obstetric emergencies
1. Shoulder dystocia
2. Cord prolapse
3. Amniotic fluid embolism
4. Uterine rupture
5. Other obstetric emergencies
Chapter 33: The puerperium
1. Physiological changes in the puerperium
2. General postnatal care
3. Lactation
4. Primary postpartum haemorrhage
5. Other problems of the puerperium
Chapter 34: Birth statistics and audit
1. Audit
2. Perinatal mortality
3. Maternal mortality
4. Intervention in pregnancy and labour
Chapter 35: Legal (UK) and ethical issues in obstetrics and gynaecology
1. Consent
2. Clinical negligence
3. Clinical governance
4. Risk management
5. Complaints procedure
6. Confidentiality
7. Regulation of fertility treatment
8. Regulation of abortion
9. Some ethical issues in obstetrics and gynaecology

Gynaecology management

Obstetric management

Appendix 1: Common drugs: safety and usage in pregnancy and breastfeeding

Appendix 2: Normal maternal ranges in pregnancy

Index

EULA

List of Illustrations

Chapter 1

Fig. 1.1 Examination of the breast.
Fig. 1.2 Abdominal examination.
Fig. 1.3 Percussion of the abdomen.
Fig. 1.4 Digital bimanual vaginal examination: (a) bimanually palpate areas 1, 2, 3 in order; (b) digital bimanual palpation of the pelvis.
Fig. 1.5 Cusco’s speculum examination of the cervix and vaginal walls. (a) Speculum enters vagina closed with opening mechanism pointing to patient’s right. (b) Speculum is inserted deep, rotated 90°, then opened. (c) The cervix comes into view once the speculum is opened.
Fig. 1.6 Sims’ speculum examination of the vaginal walls.

Chapter 2

Fig. 2.1 Oestrogen levels in a lifetime.
Fig. 2.2 Endocrine changes during puberty. FSH, follicle-stimulating hormone; GnRH, gonadotrophin-releasing hormone; LH, luteinizing hormone.
Fig. 2.3 The menstrual cycle. FSH, follicle-stimulating hormone; LH, luteinizing hormone.
Fig. 2.4 Anatomical causes of menorrhagia.
Fig. 2.5 Transvaginal ultrasound of a normal uterus and mid-cycle endometrium.
Fig. 2.6 Pipelle endometrial biopsy going through the cervix.
Fig. 2.7 Management of heavy menstruation. IUS, intrauterine system; NSAIDs, non-steroidal anti-inflammatory drugs.
Fig. 2.8 Progestogen-impregnated intrauterine system (IUS) in situ in the uterus.
Fig. 2.9 Causes of amenorrhoea.
Fig. 2.10 Cervical carcinoma.
Fig. 2.11 Distribution of premenstrual syndrome (PMS) in the population.

Chapter 3

Fig. 3.1 The uterus. (a) Blood supply and lymph drainage. (b) Relations of the pelvic organs.
Fig. 3.2 Sites of fibroids showing intramural, subserosal and submucosal placement.
Fig. 3.3 Ultrasound of fibroids in the uterus.
Fig. 3.4 Laparoscopic view of a uterus containing intramural and subserosal fibroids.
Fig. 3.5 Myomectomy.
Fig. 3.6 Adenomyosis. Source: Sutton CJ et al. Fertil Steril 1994; 62: 696–700. Reproduced with permission of Elsevier
Fig. 3.7 Endometrial polyps.
Fig. 3.8 Uterine anomalies.
Fig. 3.9 Endometrial carcinoma.
Fig. 3.10 Stages of endometrial carcinoma.

Chapter 4

Fig. 4.1 The squamocolumnar junction.
Fig. 4.2 (a) Cervical ectropion, (b) cervical polyp.
Fig. 4.3 The cervical epithelium and cervical intraepithelial neoplasia (CIN). (a) Normal cervical epithelium; proliferation in basal layer only with small nuclei. (b) CIN I–II: abnormal cells with larger nuclei proliferating in the lower one-third to two-thirds of the epithelium. (c) CIN III: abnormal cells occupying the entire epithelium. (d) Microinvasion: abnormal cells have penetrated the basement membrane.
Fig. 4.4 Natural history of cervical intraepithelial neoplasia (CIN).
Fig. 4.5 Taking a cervical smear.
Fig. 4.6 Large loop excision of transformation zone (LLETZ).
Fig. 4.7 Cervical carcinoma.
Fig. 4.8 Cone biopsy.
Fig. 4.9 Wertheim’s hysterectomy.

Chapter 5

Fig. 5.1 Anatomy of the normal ovary. (a) Relations of the ovary. (b) Transverse section of the normal ovary.
Fig. 5.2 (a) Rupture of an ovarian cyst. (b) Haemorrhage into an ovarian cyst (view from the abdomen). (c) Cyst twisting on its blood supply.
Fig. 5.3 (a) Laparoscopic photograph of a right ovarian benign epithelial cyst. (b) The cyst stripped and taken from within the ovary. The ovary returns to normal size within weeks of the operation.
Fig. 5.4 Ovarian cancer presents late as it is commonly asymptomatic.
Fig. 5.5 (a) A simple ovarian cyst. (b) Solid/ septate ovarian cyst.
Fig. 5.6 (a) Site of incision for suspected ovarian cancer (dotted line is potential extension if abdominal disease). (b) Laparotomy for ovarian cancer. The uterus, ovaries, omentum and as much of the affected tissue as possible are removed.
Fig. 5.7 The analgesic ladder. NSAIDs, non-steroidal anti-inflammatory drugs.

Chapter 6

Fig. 6.1 Anatomy and lymph drainage of the vulva.
Fig. 6.2 Lichen simplex.
Fig. 6.3 Extensive vulval warts.
Fig. 6.4 Bartholin’s abscess.
Fig. 6.5 Congenital vaginal cyst.
Fig. 6.6 Vulval carcinoma.
Fig. 6.7 Skin-sparing and separate incisions for a vulvectomy.

Chapter 7

Fig. 7.1 (a) Coronal view of the pelvis showing cardinal ligaments and the levator ani. (b) Lateral view of the pelvis showing the uterosacral ligaments and levator ani.
Fig. 7.2 Types of prolapse. (a) Normal pelvis, (b) uterine prolapse, (c) cystocoele, (d) rectocoele, (e) enterocoele.
Fig. 7.3 Appearance of cystocoele.
Fig. 7.4 Pessaries for uterovaginal prolapse. (a) Shelf pessary, (b) ring pessary.

Chapter 8

Fig. 8.1 Anatomy of the lower urinary tract and contributors to bladder and urethral pressure.
Fig. 8.2 Diagram of cystometry set-up.
Fig. 8.3 Cystometry.
Fig. 8.4 (a) Normal bladder neck. (b) Bladder neck in urodynamic stress incontinence (USI).
Fig. 8.5 Urinary fistulae: 1, urethrovaginal; 2, vesicovaginal; 3, vesicouterine; 4, ureterovaginal.

Chapter 9

Fig. 9.1 Common sites of endometriosis in the pelvis.
Fig. 9.2 Appearances of endometriosis.
Fig. 9.3 Laparoscopic view of peritoneal endometriosis: scarring with surrounding abnormal blood vessels.
Fig. 9.4 Transvaginal ultrasound photograph of an ovarian endometrioma. The ‘ground glass’ appearance of the altered blood is typical.
Fig. 9.5 Effect of gonadotrophin-releasing hormone (GnRH) analogue on pain score in patients with endometriosis.
Fig. 9.6 Pain scores over time following laparoscopic removal or observation of minimal to moderate endometriosis. Source: Sutton CJ et al. Fertil Steril 1994; 62: 696–700. Reproduced with permission of Elsevier.

Chapter 10

Fig. 10.1 Candida albicans showing budding hyphae and oval spores.
Fig. 10.2 Chlamydia trachomatis.
Fig. 10.3 Gram-negative Neisseria gonorrhoeae in pairs in a human neutrophil.
Fig. 10.4 Genital herpes.
Fig. 10.5 Treponema pallidum.
Fig. 10.6 Trichomonas vaginalis.
Fig. 10.7 Human immunodeficiency virus (HIV) particle attaching to a T lymphocyte.
Fig. 10.8 Human immunodeficiency virus (HIV) diagnoses and AIDS deaths among men infected through same-sex contact or individuals infected through heterosexual contact, UK.
Fig. 10.9 Symptoms and signs of acute PID.
Fig. 10.10 Laparoscopic photograph of severe chronic PID.
Fig. 10.11 View of pelvis affected by chronic PID.

Chapter 11

Fig. 11.1 The hormonal control of ovulation. FSH, follicle-stimulating hormone; LH, luteinizing hormone.
Fig. 11.2 Evidence of ovulation: (a) cervical mucus showing fern-like pattern; (b) spinnbarkeit formation of mucus between two glass slides; (c) temperature chart.
Fig. 11.3 Ultrasound of a polycystic ovary (PCO).
Fig. 11.4 Typical features of severe polycystic ovary syndrome (PCOS).
Fig. 11.5 Causes of anovulation (common causes shown in capital letters).
Fig. 11.6 Anorexia nervosa causes amenorrhoea and subfertility.
Fig. 11.7 Semen analysis. Antisperm antibodies causing clumping.
Fig. 11.8 Tubal blockage.
Fig. 11.9 Live birth rate per in vitro fertilization (IVF) cycle by female age.
Fig. 11.10 Transvaginal ultrasound photographs of: (a) a resting ovary at baseline, during menstruation; (b) a single 20 mm follicle, after ovulation in an unstimulated cycle; (c) multiple 15–20 mm follicles during a gonadotrophin-stimulated cycle.
Fig. 11.11 Process of an in vitro fertilization (IVF) cycle.
Fig. 11.12 Intracytoplasmic sperm injection (ICSI).

Chapter 12

Fig. 12.1 The combined oral contraceptive.
Fig. 12.2 Major complications of the combined oral contraceptive.
Fig. 12.3 Nexplanon.
Fig. 12.4 The male condom.
Fig. 12.5 (a) The cervical cap. (b) The diaphragm.
Fig. 12.6 Intrauterine devices (IUDs). (a) Copper T in uterus, (b) intrauterine system (IUS), (c) Gynefix.
Fig. 12.7 Female sterilization. View of uterine fundus with Filshie clips on tubes.
Fig. 12.8 Female sterilization: microinserts placed hysteroscopically into fallopian tubes.

Chapter 13

Fig. 13.1 Oestrogen levels in a lifetime.
Fig. 13.2 Changes and clinical features of oestrogen deficiency.
Fig. 13.3 Deaths by cause, women, UK 2014 (redrawn from the British Heart Foundation). CVD, cardiovascular disease.
Fig. 13.4 Ovarian responsiveness to pituitary hormones. (a) Reproductive years: feedback control between ovary and hypothalamic–pituitary axis. (b) Postmenopausal years: unresponsive ovaries produce no oestrogen or inhibin. Lack of feedback on hypothalamus–pituitary axis causes high levels of follicle-stimulating hormone (FSH) and luteinizing hormone (LH).
Fig. 13.6 Bone density in oestrogen users and non-users.
Fig. 13.5 Preparations of hormone replacement therapy (HRT): (a) patch, (b) implant, (c) gel and (d) pills.

Chapter 14

Fig. 14.1 (a) Fertilization and development of the blastocyst. (b) Implantation: day 6.
Fig. 14.2 Miscarriage rates by maternal age.
Fig. 14.3 (a) Threatened miscarriage. (b) Incomplete miscarriage. (c) Missed miscarriage.
Fig. 14.4 Three-dimensional image of live fetus at 11 weeks’ gestation.
Fig. 14.5 Sites of ectopic pregnancy.
Fig. 14.6 Ultrasound of ectopic pregnancy. It is unusual to visualize the ectopic pregnancy with ultrasound.
Fig. 14.7 The ectopic pregnancy (in Fig. 14.6) removed by salpingectomy.
Fig. 14.8 Laparoscopic photograph of an unruptured tubal ectopic pregnancy.
Fig. 14.9 Ultrasound of a molar pregnancy.

Chapter 15

Fig. 15.1 Gynaecological endoscopy.
Fig. 15.2 Transcervical resection of endometrium (TCRE). The monopolar cutting loop creates ‘trenches’ within the endometrium until it is completely removed.
Fig. 15.3 Laparoscopic photograph of a normal pelvis. The right ovary contains a 2 cm preovulatory follicle.
Fig. 15.4 Hysterectomy. (1) Blood: the anastomosis between uterine and ovarian arteries. If the ovaries are removed, the ovarian artery and vein are ligated instead. Ligament: the round ligament. (2) Blood: the main uterine artery. Ligament: the cardinal ligament. The bladder is first dissected off the cervix and upper vagina, to prevent injury to it or to the ureters, which are close. (3) Blood: the cervicovaginal branches of the uterine artery supplying the cervix and upper vagina. Ligament: the uterosacral ligament.
Fig. 15.5 Dilatation and curettage (D&C).
Fig. 15.6 Bifurcated mesh in position for hysteropexy.
Fig. 15.7 (a) Tension-free vaginal tape (TVT). The mid-urethra and bladder neck are supported by the tape. (b) Transobturator tape (TOT).

Chapter 16

Fig. 16.1 The obstetric ‘wheel’.
Fig. 16.2 Crown–rump length of fetus at 12+ weeks.
Fig. 16.3 Blood pressure measurement and urinalysis are essential.
Fig. 16.4 Abdominal palpation of uterine size.
Fig. 16.5 Abdominal palpation. Step 1: Fundal palpation and measurement of symphysis–fundal height.
Fig. 16.6 Abdominal palpation. Step 2: Examination of fetal parts.
Fig. 16.7 Abdominal palpation. Step 3: Examination of presentation.
Fig. 16.8 Longitudinal lie (cephalic presentation in this instance).
Fig. 16.9 Transverse lie.
Fig. 16.10 Engagement of the fetal head.
Fig. 16.11 Postnatal examination.

Chapter 17

Fig. 17.1 UK maternal mortality according to age. Source: Centre for Child and Maternal Enquiries (CMACE). BJOG 2011; 118 (Suppl. 1): 1–203. Reproduced with permission of John Wiley & Sons Ltd.
Fig. 17.2 Pelvic tilt at antenatal classes.
Fig. 17.3 Basic antenatal care in nulliparous women. CTG, cardiotocography; LMP, last menstrual period; MW, midwife.
Fig. 17.4 Obstetric examination at antenatal visits in the late third trimester.

Chapter 18

Fig. 18.1 Normal nuchal translucency.
Fig. 18.2 Enlarged nuchal translucency.
Fig. 18.3 Photograph of enlarged nuchal translucency.
Fig. 18.4 Abdominal cyst at nuchal scan.
Fig. 18.5 Amniocentesis.
Fig. 18.6 Maternal age and risk of trisomies.
Fig. 18.7 Neural tube defect (NTD): anencephaly.
Fig. 18.8 Enlarged cerebral ventricles.
Fig. 18.9 Normal heart: transverse view of chest.
Fig. 18.10 Gastroschisis.
Fig. 18.11 Newborn with gastroschisis.
Fig. 18.12 Transverse section of fetal chest containing congenital cystic adenomatous malformation (CCAM).
Fig. 18.13 Uterus with polyhydramnios.
Fig. 18.14 Fetal hydrops: pleural effusions and skin oedema in transverse section of fetal chest.
Fig. 18.15 Hydropic fetus.

Chapter 19

Fig. 19.1 Genital herpes simplex.
Fig. 19.2 Herpesvirus.
Fig. 19.3 Electron micrograph of HIV virus. Source: Rogstad K. ABC of STIs, 6th edn. Reproduced with permission of John Wiley & Sons Ltd.
Fig. 19.4 Decline in human immunodeficiency virus (HIV) particles with highly active antiretroviral therapy (HAART).
Fig. 19.5 Streptococcus infection.

Chapter 20

Fig. 20.1 Blood pressure changes in pregnancy.
Fig. 20.2 Ultrasound of the maternal–placental interface. Red: flow away from probe; blue: flow towards probe.
Fig. 20.3 Clinical features of pre-eclampsia.
Fig. 20.4 Complications of pre-eclampsia. IUGR, intrauterine growth retardation.
Fig. 20.5 Magnetic resonance imaging of haemorrhagic stroke.
Fig. 20.6 Section through infarcted placenta.

Chapter 21

Fig. 21.1 Distribution of glucose tolerance in the non-pregnant and pregnant population.
Fig. 21.2 Fetal complications of diabetes.
Fig. 21.3 Maternal complications of diabetes.
Fig. 21.4 The multidisciplinary approach to diabetes in pregnancy.
Fig. 21.5 Accelerated fetal growth of a fetus with a diabetic mother.
Fig. 21.6 Goitre.
Fig. 21.7 Clinical features of pyelonephritis.
Fig. 21.8 UK deaths from thromboembolism. Source: Centre for Child and Maternal Enquiries (CMACE) BJOG 2011; 118(Suppl. 1): 1–203. Reproduced with permission of John Wiley & Sons Ltd.
Fig. 21.9 Venous thromboembolism in pregnancy.
Fig. 21.10 CT angiogram of pulmonary embolus.
Fig. 21.11 Anaemia in pregnancy.
Fig. 21.12 Picture of blood film of iron deficiency anaemia.

Chapter 22

Fig. 22.1 Mendelian inheritance of D/d gene pair.
Fig. 22.2 The mechanism of red cell isoimmunization.
Fig. 22.3 Middle cerebral artery (MCA) Doppler.

Chapter 23

Fig. 23.1 Postnatal ultrasound of cystic periventricular leucomalacia, a precursor to cerebral palsy.
Fig. 23.2 Incidence of preterm delivery. Source: Oxford data.
Fig. 23.3 Risk factors for preterm delivery.
Fig. 23.4 Cervical length.
Fig. 23.5 Abnormal cervical length.
Fig. 23.6 Cervical suture. Transverse section of the cervix.
Fig. 23.7 Monitoring the patient with preterm prelabour rupture of the membranes.

Chapter 24

Fig. 24.1 (a) Marginal placenta praevia. (b) Major placenta praevia (abnormal lie and malpresentation are common).
Fig. 24.2 Ultrasound of placenta praevia.
Fig. 24.3 3-D power Doppler ultrasound of placenta accreta.
Fig. 24.4 (a) Revealed abruption. (b) Concealed abruption.
Fig. 24.5 Clinical features of placental abruption.
Fig. 24.6 Terminal fetal heart bradycardia with placental abruption.
Fig. 24.7 Vasa praevia.
Fig. 24.8 Other causes of antepartum haemorrhage (APH). (a) Vasa praevia. (b) Ruptured uterus (intra-abdominal loss usually predominates). (c) Cervical carcinoma.

Chapter 25

Fig. 25.1 Consistent growth of a small fetus.
Fig. 25.2 Slowed growth suggestive of placental disease.
Fig. 25.3 Normal and abnormal uterine artery Doppler.
Fig. 25.4 (a) Normal growth of the head; (b) slowed growth of the abdomen.
Fig. 25.5 (a) Normal umbilical artery end-diastolic flow; (b) reversed end-diastolic flow.
Fig. 25.6 Ultrasound of middle cerebral artery.
Fig. 25.7 Ultrasound of abnormal ductus venosus.
Fig. 25.8 Normal antenatal CTG.
Fig. 25.9 Management of preterm IUGR. AEDF, absent end-diastolic flow; BP, blood pressure; CMV, cytomegalovirus; CS, caesarean section; CTG, cardiotocography.
Fig. 25.10 Risk of stillbirth and infant mortality according to gestational age.

Chapter 26

Fig. 26.1 (a) Longitudinal lie. (b) Transverse lie.
Fig. 26.2 Causes of transverse lie and breech presentation.
Fig. 26.3 Cord prolapse.
Fig. 26.4 Types of breech presentation. (a) Extended. (b) Flexed. (c) Footling.
Fig. 26.5 External cephalic version (ECV).
Fig. 26.6 Breech delivery. (a) As the buttocks distend the perineum, perform the episiotomy. (b) A finger behind the knee delivers the legs. (c) A finger hooks each arm down. (d) Forceps delivering the head once the arms are delivered.

Chapter 27

Fig. 27.1 Mechanisms of twinning.
Fig. 27.2 Complications of twin pregnancies.
Fig. 27.3 Twins with growth discordancy.
Fig. 27.4 Monochorionic twin placenta with shared blood vessels.
Fig. 27.5 Ultrasound of monochorionic diamniotic twin placenta.
Fig. 27.6 Monochorionic monoamniotic twin placenta.
Fig. 27.7 Ultrasound of dichorionic twins in early pregnancy showing the lambda sign.
Fig. 27.8 Fetal growth chart showing discordant growth of twins.
Fig. 27.9 Ultrasound of fetal heart showing tricuspid regurgitation.
Fig. 27.10 Quintuplet girls delivered in Oxford in 2007. By kind permission of the parents.
Fig. 27.11 Different presentations of twins.

Chapter 28

Fig. 28.1 The powers.
Fig. 28.2 Anatomy of the pelvis showing the three planes (a, b and c), and where they are on a lateral view of the pelvis (d).
Fig. 28.3 Descent of the head in labour in relation to the ischial spines.
Fig. 28.4 (a) Fetal head from above, showing sutures and fontanelles. (b) Fetal head from the side.
Fig. 28.5 Attitude of the fetal head showing how extension of the head changes the presenting diameter and what is palpable on vaginal examination.
Fig. 28.6 View from below showing rotation of the head (position) according to the three planes of the pelvis.
Fig. 28.7 Diagram of moulding showing compression and overlap of sutures.
Fig. 28.8 (a–f) Movement of the head in labour.
Fig. 28.9 Effacement and dilatation of the cervix.
Fig. 28.10 Head delivery over the perineum by extension.

Chapter 29

Fig. 29.1 Maternal anxiety is bad for labour.
Fig. 29.2 Aortocaval compression. If the patient is allowed to lie flat on her back, the inferior vena cava is compressed.
Fig. 29.3 Former World Health Organization partogram. Reproduced with permission of WHO.
Fig. 29.4 Amniotomy.
Fig. 29.5 A partogram showing delay in first stage managed with oxytocin. Reproduced with permission of WHO.
Fig. 29.6 The occipito-posterior (OP) position associated with extension of the head.
Fig. 29.7 The occipito-transverse (OT) position: delivery is impossible without rotation.
Fig. 29.8 Brow presentation.
Fig. 29.9 Face presentation (chin is posterior).
Fig. 29.10 (a) Pinard’s stethoscope for intermittent auscultation in labour. (b) Fetal scalp electrode for electronic fetal monitoring in labour.
Fig. 29.11 (a) Acute fetal distress; the fetus is dying. (b) Normal cardiotocography (CTG); acceleration of the fetal heart with contractions. (c) Early decelerations are synchronous with a contraction. (d) Late decelerations, tachycardia, reduced variability suggestive of fetal distress.
Fig. 29.12 Fetal blood sampling from scalp in labour.
Fig. 29.13 Fetal vessels in membranes in vasa praevia.
Fig. 29.14 Epidural analgesia; transverse section of the spinal column of L3–4.
Fig. 29.15 Spinal analgesia, transverse section of the spinal column.
Fig. 29.16 Management of first stage. ARM, artificial rupture of membranes; LSCS, lower segment caesarean section.
Fig. 29.17 Management of second stage.
Fig. 29.18 Episiotomy.
Fig. 29.19 Normal delivery. (a) ‘Guarding’ the perineum as the head distends it. (b) The head delivers. (c) The head restitutes. (d) The anterior shoulder is delivered by gentle downward traction until the next contraction. (e) The posterior shoulder is delivered by gentle upward traction.
Fig. 29.20 Management of third stage. Delivery of the placenta.
Fig. 29.21 Perineal trauma. (a) First-degree tear. (b) Second-degree tear. (c) Mediolateral episiotomy. (d) Third-degree tear.
Fig. 29.22 Water birth.

Chapter 30

Fig. 30.1 The Bishop’s score.
Fig. 30.2 Sweeping the membranes. A finger is inserted through the cervix and rotated: the membranes are peeled off the lower segment.
Fig. 30.3 Rupture of scar from previous caesarean section.
Fig. 30.4 Ascending infection can complicate prelabour rupture of the membranes.

Chapter 31

Fig. 31.1 The ventouse.
Fig. 31.2 Forceps: (a) non-rotational; (b) rotational.
Fig. 31.3 (a) Side view of pelvis showing level of head for mid-cavity and low-cavity forceps delivery. (b) Forceps and ventouse in position on the fetal head showing direction of traction.
Fig. 31.4 Layers of the abdominal wall for delivery of fetus by caesarean section.
Fig. 31.5 Ultrasound of placenta accreta.

Chapter 32

Fig. 32.1 Erb’s palsy of right arm in characteristic ‘waiter’s tip’ position.
Fig. 32.2 Cord prolapse (here associated with flexed breech presentation).
Fig. 32.3 Massive ‘primary’ rupture of the uterus with extrusion of the fetus.
Fig. 32.4 Inverted uterus.

Chapter 33

Fig. 33.1 Diagram of uterine involution.
Fig. 33.2 Causes and sites of postpartum haemorrhage (PPH).
Fig. 33.3 Causes and sites of postpartum pyrexia.
Fig. 33.4 Postpartum urinary problems.
Fig. 33.5 Ultrasound of disrupted anal sphincter.

Chapter 34

Fig. 34.1 UK stillbirths and neonatal mortality rates (2000–2008). Source: CMACE (2010).
Fig. 34.2 Long-term changes in maternal mortality in the UK.
Fig. 34.3 UK maternal mortality rates (1985–2013). Source: Knight M et al. (eds) on behalf of MBRRACE-UK. Saving Lives, Improving Mothers’ Care – Surveillance of maternal deaths in the UK 2011–13 and lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009–13. © 2015 National Perinatal Epidemiology Unit, University of Oxford.

Chapter 35

Fig. 35.1
Fig. 35.2 Consent form.

Acknowledgements

I am grateful to the many friends and colleagues in the UK and Ireland who have made criticisms in their areas of expertise and have helped with the preparation of this book. These are Mr Mike Bowen, Dr Bill Boyd, Dr Patricia Boyd, Dr Bridgette Byrne, Dr Paul Dewart, Dr Valerie Donnelly, Dr Anne Edwards, Dr Michael Foley, Miss Michelle Fynes, Mr Mike Gillmer, Miss Catharine Greenwood, Dr Jonathan Hobson, Mr James Hopkisson, Miss Pauline Hurley, Mr Simon Jackson, Dr Catherine James, Dr Declan Keane, Mr Sean Kehoe, Mr Stephen Kennedy, Dr Peter Lenehan, Dr Graham Lloyd-Jones, Dr Graz Luzzi, Dr Dermott MacDonald, Dr Pamela MacKinnon, Dr Peter McParland, Mr Enda McVeigh, Miss Kathryn MacQuillan, Dr Jane Mellanby, Miss Jo Morrison, Miss Jane Moore, Miss Alice Nelson, Miss Brenda O'Kelly, Miss Meghana Pandit, Dr John Picard, Miss Charlotte Porter, Professor Chris Redman, Miss Margaret Rees, Dr Robin Russell, Miss Susan Sellers, Dr Sarah Sheikh, Dr Orla Sheil, Mr Alex Slack, Mr Alexander Smarason, Mr Kevin Smith, Professor Philip Steer, Mr Alex Swanton, and Dr Mary Wingfield. I am indebted to Blackwell Science, particularly Ms Rebecca Huxley, Dr Andrew Robinson and Dr Michael Stein for their faith, help and encouragement, and to the medical students of the Royal College of Surgeons in Ireland and of Oxford University for their criticisms. And I am particularly grateful to Ms Jane Fallows for her illustrations. Most of all, however, I thank Susan and Cicely Impey for their support and patience during the writing of this book.

Acknowledgements for the fifth edition

In addition to the many people who helped with the first edition, we would like to thank Miss Natalia Price, Dr Jackie Sherrard, Miss Catharine Greenwood, Dr Michael Yousif, Mr Simon Jackson, Prof Margaret Rees, Dr Lucy Mackillop, Miss Ruth Houlden, Prof Ahmed Ahmed, Mr Richard Clayton and Mr Charles Muteshi.

Lawrence Impey
Tim Child

List of abbreviations

ACA	anticardiolipin antibody
ACE	angiotensin-converting enzyme
ACT	artemisin combination therapy
ACTH	adrenocorticotrophic hormone
AD	Alzheimer's disease
AEDF	absent end-diastolic flow
AFC	antral follicle count
AFP	alpha fetoprotein
AIDS	acquired immune deficiency syndrome
AIS	androgen insensitivity syndrome
ALP	alkaline phosphatase
ALT	alanine aminotransferase
AMH	antimullerian hormone
AP	antero-posterior
APH	antepartum haemorrhage
APS	antiphospholipid syndrome
ARDS	adult respiratory distress syndrome
ARM	artificial rupture of membranes
ASD	atrial septal defect
AST	aspartate aminotransferase
AUB	abnormal uterine bleeding
AV	aerobic vaginitis
BCG	Bacille bilié de Calmette–Guérin
β-hCG	human chorionic gonadotrophin beta-subunit
BMD	bone mineral density
BMI	body mass index
BP	blood pressure
BSO	bilateral salpingo-oophorectomy
BV	bacterial vaginosis
CA	carcinoma
CA 125	serum cancer antigen 125
CCAM	congenital cystic adenomatous malformation
CGH	comparative genomic hybridization
CGIN	cervical glandular intraepithelial neoplasia
CHC	combined hormonal contraception
CIN	cervical intraepithelial neoplasia
CMV	cytomegalovirus
CNS	central nervous system
CNST	Clinical Negligence Scheme for Trusts
COC	combined oral contraceptive
CPP	chronic pelvic pain
CPR	cerebroplacental ratio; cardiopulmonary resuscitation
CRL	crown–rump length
CRP	C-reactive protein
CSF	cerebrospinal fluid
CT	computed tomography
CTG	cardiotocography
CVA	cerebrovascular accident
CVD	cardiovascular disease
CVP	central venous pressure
CVS	chorionic villus sampling
D&C	dilatation and curettage
DCDA	dichorionic diamniotic
DES	diethylstilboestrol
DEXA	dual-energy X-ray absorptiometry
DI	donor insemination
DIC	disseminated intravascular coagulation
DLE	diathermy loop excision
DNA	deoxyribonucleic acid
DVT	deep vein thrombosis
DZ	dizygotic
ECG	electrocardiogram
ECMO	extracorporeal membrane oxygenation
ECV	external cephalic version
EDD	expected day of delivery
EFM	electronic fetal monitoring
EIA	enzyme immunoassay
EPAU	early pregnancy assessment unit
EPDS	Edinburgh Postnatal Depression Scale
ERPC	evacuation of retained products of conception
eSET	elective single embryo transfer
ESR	erythrocyte sedimentation rate
EUA	examination under anaesthetic
FBC	full blood count
FBS	fetal blood sampling
FDA	Food and Drug Administration
FER	frozen embryo replacement
FFP	fresh frozen plasma
FGM	female genital mutilation
FGR	fetal growth restriction
FHR	fetal heart rate
FIGO	International Federation of Gynaecology and Obstetrics
FISH	fluorescence in situ hybridization
FPR	false-positive rate
FSD	female sexual dysfunction
FSH	follicle-stimulating hormone
G&S	group and save
GBS	group B streptococcus
GFR	glomerular filtration rate
GMC	General Medical Council
GnRH	gonadotrophin-releasing hormone
GSI	genuine stress incontinence
GTD	gestational trophoblastic disease
GTT	glucose tolerance test
HAART	highly active antiretroviral therapy
Hb	haemoglobin
HbF	fetal haemoglobin
hCG	human chorionic gonadotrophin
HCV	hepatitis C virus
HELLP	(syndrome of) haemolysis, elevated liver enzymes and low platelets
HFEA	Human Fertilization and Embryology Authority
HIV	human immunodeficiency virus
HMB	heavy menstrual bleeding
HNPCC	hereditary non-polyposis colorectal cancer
HPV	human papilloma virus
HRT	hormone replacement therapy
HSG	hysterosalpingogram
HSV	herpes simplex virus
HVS	high vaginal swab
IA	intermittent auscultation
IBS	irritable bowel syndrome
ICAS	Independent Complaints Advocacy Service
ICSI	intracytoplasmic sperm injection
Ig	immunoglobulin
IM	intramuscular
IMB	intermenstrual bleeding
IPT	intermittent preventive treatment
IUD	intrauterine device
IUGR	intrauterine growth restriction
IUI	intrauterine insemination
IUS	intrauterine system
IV	intravenous
IVF	in vitro fertilization
IVP	intravenous pyelogram
JVP	jugular venous pressure
LARC	long-acting reversible contraceptive
LAVH	laparoscopic-assisted vaginal hysterectomy
LBC	liquid-based cytology
LDA	low-dose aspirin
LDH	lactic dehydrogenase
LFT	liver function test
LH	luteinizing hormone
LLETZ	large loop excision of transformation zone
LMP	last menstrual period
LMWH	low molecular weight heparin
LN	lymph node
LSCS	lower segment caesarean section
LUNA	laparoscopic uterine nerve ablation
MC	monochorionic
MCA	middle cerebral artery
MCDA	monochorionic diamniotic
MCHC	mean cell haemoglobin concentration
MCMA	monochorionic monoamniotic
MCV	mean cell volume
MDT	multidisciplinary team
MHT	menopausal hormone therapy
MOH	massive obstetric haemorrhage
MRI	magnetic resonance imaging
MSAFP	maternal serum alpha fetoprotein
MSU	mid-stream urine
MZ	monozygotic
NAAT	nucleic acid amplification test
NEC	necrotizing enterocolitis
NGS	next generation sequencing
NHS	National Health Service
NICE	National Institute for Health and Care Excellence
NIPT	non-invasive prenatal testing
NPV	negative predictive value
NRT	nicotine replacement therapy
NSAID	non-steroidal anti-inflammatory drug
NTD	neural tube defect
NVP	nausea and vomiting of pregnancy
OA	occipito-anterior
OAB	overactive bladder
OCD	obsessive compulsive disorder
OCP	oral contraceptive pill
OHSS	ovarian hyperstimulation syndrome
OP	occipito-posterior
OT	occipito-transverse
PAPPA	pregnancy-associated plasma protein A
PBS	painful bladder syndrome
PCA	patient-controlled analgesia
PCB	postcoital bleeding
PCO	polycystic ovary
PCOS	polycystic ovary syndrome
PCP	Pneumocystis carinii pneumonia
PCR	protein:creatinine ratio
PDA	patent ductus arteriosus
PET	pre-eclamptic toxaemia
PFMT	pelvic floor muscle training
PGD	preimplantation genetic diagnosis
PGE2	prostaglandin E2
PGF2a	prostaglandin F2a
PGS	preimplantation genetic screening
PI	Pearl Index; pulsatility index
PID	pelvic inflammatory disease
PlGF	placental growth factor
PM	postmortem
PMB	postmenopausal bleeding
PMS	premenstrual syndrome
POP	progestogen-only pill
PPH	postpartum haemorrhage
PPV	positive predictive value
PSTT	placental site trophoblastic tumour
PSV	peak velocity in systole
PTSD	post-traumatic stress disorder
PTU	propylthiouracil
PUL	pregnancy of unknown location
PV	per vaginam
RCT	randomized controlled trial
REDF	reversed end-diastolic flow
RMI	risk of malignancy index
SARA	sexually acquired reactive arthritis
SBR	serum bilirubin
SD	standard deviation
SERM	selective estrogen receptor modulator
SFD	small for dates
SFH	symphysis–fundal height
SGA	small for gestational age
SHBG	steroid hormone-binding globulin
SIDS	sudden infant death syndrome
SLE	systemic lupus erythematosus
SLNB	sentinel lymph node biopsy
SMM	surgical management of miscarriage
SNRI	serotonin and noradrenaline reuptake inhibitor
SPRM	selective progesterone receptor modulator
SROM	spontaneous rupture of membranes
SSR	surgical sperm retrieval
SSRI	selective serotonin reuptake inhibitor
STI	sexually transmitted infection
STV	short-term variability
T3	triiodothyronine
T4	thyroxine
TAH	total abdominal hysterectomy
TAPS	twin anaemia polycythaemia sequence
TB	tuberculosis
TCRE	transcervical resection of endometrium
TCRF	transcervical resection of fibroid
TEDS	thromboembolic disease stockings
TENS	transcutaneous electrical nerve stimulation
TFT	thyroid function test
TLH	total laparoscopic hysterectomy
TOP	termination of pregnancy
TOT	transobdurator tape
TRAP	twin reversed arterial perfusion
TSH	thyroid-stimulating hormone
TTN	transient tachypnoea of the newborn
TTTS	twin–twin transfusion syndrome
TURP	transurethral resection of prostate
TVS	transvaginal sonography
TVT	tension-free vaginal tape
U&E	urea and electrolytes
UAE	uterine artery embolization
UDCA	ursodeoxycholic acid
UmbA	umbilical artery
USI	urodynamic stress incontinence
USS	ultrasound scan
UTI	urinary tract infection
VBAC	vaginal delivery after a previous caesarean section
VDRL	Venereal Disease Research Laboratories
VE	vaginal examination
VEGF	vascular endothelial growth factor
VH	vaginal hysterectomy
VIN	vulvar intraepithelial neoplasia
VMA	vanillylmandelic acid
VQ	ventilation/perfusion
VSD	ventricular septal defect
VTE	venous thromboembolism
WBC	white blood cell count
WHO	World Health Organization