Dutta's Textbook of Obstetrics PDF

DC Dutta’s Textbook of OBSTETRICS including Perinatology and Contraception OTHER BOOKS BY THE SAME AUTHOR Textbook of Gynecology A Guide to Clinical Obstetrics and Gynecology Bedside Clinics & Viva-voce in Obstetrics and Gynecology Master Pass in Obstetrics and Gynaecology Emergenci...

DC Dutta’s Textbook of OBSTETRICS including Perinatology and Contraception OTHER BOOKS BY THE SAME AUTHOR Textbook of Gynecology A Guide to Clinical Obstetrics and Gynecology Bedside Clinics & Viva-voce in Obstetrics and Gynecology Master Pass in Obstetrics and Gynaecology Emergencies in Manipulative and Operative Obstetrics DC Dutta’s Textbook of OBSTETRICS including Perinatology and Contraception Eighth Edition DC DUTTA MBBS, DGO, MO (CaL) Professor and Head, Department of Obstetrics and Gynecology Nilratan Sircar Medical College and Hospital, Kolkata, India Edited by HIRALAL KONAR (HONS; GOLD MEDALIST) MBBS (CaL), MD (PGI), DNB (INDIA) MNAMS, FACS (USA), FRCOG (LONDON) Chairman, Indian College of Obstetricians and Gynecologists Professor, Department of Obstetrics and Gynecology Calcutta National Medical College and CR Hospital, Kolkata, India One-time Professor and Head, Dept., Obst. & Gyne. Midnapore Medical College and Hospital, West Bengal University of Health Sciences, Kolkata, India Rotation Registrar in Obstetrics, Gynecology and Oncology Northern and Yorkshire Region, Newcastle-upon-Tyne, UK Examiner of MBBS, DGO, MD and PhD of different Indian universities and National Board of Examination, New Delhi, India The Health Sciences Publisher New Delhi | London | Philadelphia | Panama  Jaypee Brothers Medical Publishers (P) Ltd Headquarters Jaypee Brothers Medical Publishers (P) Ltd 4838/24, Ansari Road, Daryaganj New Delhi 110 002, India Phone: +91-11-43574357 Fax: +91-11-43574314 Email: [email protected] Overseas Offices J.P. Medical Ltd Jaypee-Highlights Medical Publishers Inc 83 Victoria Street, London City of Knowledge, Bld. 237, Clayton SW1H 0HW (UK) Panama City, Panama Phone: +44 20 3170 8910 Phone: +1 507-301-0496 Fax: +44 (0)20 3008 6180 Fax: +1 507-301-0499 Email: [email protected] Email: [email protected] Jaypee Medical Inc Jaypee Brothers Medical Publishers (P) Ltd The Bourse 17/1-B Babar Road, Block-B, Shaymali 111 South Independence Mall East Mohammadpur, Dhaka-1207 Suite 835, Philadelphia, PA 19106, USA Bangladesh Phone: +1 267-519-9789 Mobile: +08801912003485 Email: [email protected] Email: [email protected] Jaypee Brothers Medical Publishers (P) Ltd Bhotahity, Kathmandu, Nepal Phone: +977-9741283608 Email: [email protected] Website: www.jaypeebrothers.com Website: www.jaypeedigital.com © Copyright reserved by Mrs Madhusri Konar 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) of the book. All rights reserved. No part of this publication may be reproduced, stored or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission in writing of the publishers. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. Information contained in this book is up-to-date, believed to be reliable when checked with the sources and is in accordance with the accepted standard at the time of publication. However, with ongoing research and passage of time, new knowledge may modify some of it. The reader should, therefore, approach the book with a realistic attitude (particularly the drugs and doses) and should carry the professional responsibility. The readers are asked to verify the information contained herein from other sources. Neither the publisher nor the author(s)/editor(s) assume(s) 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 is/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] Textbook of Obstetrics Enlarged & Revised Reprint of Seventh Edition: November 2013 Eighth Edition: 2015 ISBN 978-93-5152-723-7 Printed at  Dedicated to The students of obstetrics past and present  Preface to the Eighth Edition DC Dutta’s Textbook of Obstetrics is in service to the medical fraternity for the last 31 years. It primarily aims at the medical students, trainee residents, practicing doctors and the midwives. It has evolved to provide comprehensive and updated information in a concise and easy-to-read format. The eighth edition has come out with an international standard to meet the overwhelming demand in many parts of the world. All the chapters have been extensively revised and strategically reorganized. Medical advances up to the time of publication have been incorporated. Contemporaneous guidelines from different professional and academic organizations like RCOG, ACOG, WHO, FIGO, NICHD, CDC, NICE, ICOG and DIPSI are provided. Management options based on experience, derived from large obstetric services are also mentioned. This is particularly so in a situation where no evidence exists or it is difficult to follow due to limitation of resources. Objective of this edition is to provide current cutting edge information, to enable the candidates to qualify the examination in India and its equivalents internationally. Dutta’s eighth edition in its fully coloured format is profusely illustrated with a total number of 320 line drawings, sketches and photographs. In recognition of the advanced technology, the book provides sonograms, including Doppler studies, M R Images, microphotographs, data graphs and laparoscopic images. All these are in most vivid colors. Practical obstetrics (Chapter 42) with a total number of 52 high-quality photographs of instruments, specimens, sonograms, M R Images and drugs is of immense value, specifically for the practical part of the examination. The total information in Chapter 42 amounts to a mini textbook-cum-colour atlas in obstetrics. For easy text reference and reading, contents and index have also been expanded. A list of abbreviations and a few updated reviews with websites are provided. The uniqueness of this text lies in its presentations, which are simple, lucid and unambiguous. Presentation of summary tables, algorithms and key-points for each chapter are a special attraction. These are for quick revision and recapitulation before the examination. This book is available in various e-Book formats. Dutta’s has a long-standing association with its sister books: Textbook of Gynecology (6th Edition–2013), Bedside Clinics and Viva-voce (1st Edition–2015), Master Pass in Obstetrics and Gynaecology (2nd Edition–2015) I had the opportunity to visit many of the medical institutions in this country and abroad. The feedback that I received from the teachers and students was invaluable. Many of these suggestions have been addressed to in this edition. I do hope this comprehensive textbook will continue to be of immense educational resource to the readers as ever. I am grateful to all who have taught me, most of all the patients and my beloved students. viii Textbook of Obstetrics According to the author’s desire, the book is dedicated to the students of obstetrics—past and present, who strive continuously to improve maternal and newborn’s health, wherever they work. P-13, New CIT Road Hiralal Konar Kolkata – 700 014  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.), Professor, Dept. of Obst. and Gyne., Nilratan Sircar Medical College, Calcutta; Dr KM Gun, MBBS, DGO, MO (CaL), FRCOG (Eng.), FRCS (Edin.), FACS, Professor, Dept. of Obst. and Gyne., Medical College, Calcutta; Dr Santosh Kr Paul, MBBS, DGO, MO (CaL), Reader, Dept. of Obst. and Gyne., Nilratan Sircar Medical College, Calcutta; Dr B Hore, MBBS, DA, MS (CaL), Professor and Head of the Dept. of Anesthesiology, North Bengal Medical College, Siliguri; Dr BC Lahari, MBBS, DGO, MO (CaL), FRCS (Edin.), FRCOG (Eng.), FACS (USA), FAMS (Ind.), Professor, Dept. of Obst. and Gyne., Medical College, Calcutta; Dr P Raha, MBBS, DTM & H, PhD, FCAL, Professor, Dept. of Pathology and Bacteriology, RG Kar Medical College, Calcutta; Dr J Mitra, MBBS, DGO, MO (CaL), FLCS, FIMS, FRCOG, Professor, Dept. of Obst. and Gyne., Institute of Postgraduate Medical Education and Research, Calcutta; Dr Aroti Roy, MBBS, FRCOG (Eng.), Professor Dept. of Obst. and Gyne., RG Kar Medical College, Calcutta, and Dr H Dattagupta, MBBS, DGO, FRCOG (Eng.), Asstt. Professor, Dept. of Obst. and Gyne., Medical College, Calcutta; Dr NN Roychowdhury, MBBS, DGO, MO (CaL), PhD, FRCS, FRCOG, FACS, FAMS, Professor, Dept. of Obst. and Gyne., Medical College, Calcutta; Dr N Chowdhury, MBBS, DGO, MO (CaL), Professor, Dept. of Obst. and Gyne., Institute of Postgraduate Medical Education and Research, Calcutta. x Textbook of Obstetrics Dr NG Das, BSc, MBBS, MS (CaL), Professor and Head of the Dept. of Anatomy, Nilratan Sircar Medical College, Calcutta; Dr PK Talukdar, MBBS (CaL), DCH (Lond.), MRCP (Lond.), MRCP (Eng.), Lecturer, Pediatrics, NRS Medical College, Calcutta; Dr Subir Kumar Dutta, MBBS, DCP, MD (Path. & Bact.), Lecturer, Dept. of Pathology and Bacteriology, University College of Medicine, Calcutta; Dr Samar Rudra, MBBS, DGO, MRCOG (Eng.), Ramakrishna Mission Seva Pratishthan, Calcutta. I have much pleasure in expressing my cordial appreciation to the house-surgeons, internees and students of Nilratan Sircar Medical College, Calcutta for all the help they have rendered in the 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. I express my sincere thanks to my publisher ‘Central Educational Enterprises’ for their sincere efforts in publishing the book within the stipulated period in spite of the adverse circumstances. 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 DC Dutta 8th September, 1983 P-13, New CIT Road Kolkata – 700 014  Contents xi Acknowledgments The job of editing such a comprehensive text is stupendous. 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 acknowledge my legacy to all the teachers, related authors and the publishers. I express my sincere thanks to all the teachers and students of different medical institutes, midwifery institutes, nursing colleges in India and abroad for their valued suggestions, new ideas and contribution of photographs. The editor always welcomes the views of the students and the teachers through online access of the Student-Teacher Platform in our websites hiralalkonar.com and dcdutta.com, and e-mail ID [email protected]. The eighth edition gratefully acknowledges the insightful wisdom of the following teachers, who are associated since the first edition of the book. Dr KM Gun MD, FRCOG, FRCS, FACS, Professor (Rtd), Dr BN Chakravorty MD, FRCOG, DSc, Director, Institute of Reproductive Medicine, Kolkata, Dr B Hore MD, Professor (Rtd), Consultant Anesthetist, Dr Subir Kumar Dutta MD, Professor (Rtd), Consultant Pathologist for their contribution, continued guidance and valuable suggestions. The manuscript of the chapter on perinatology (Chapter 33) has been thoroughly read and authoritatively revised by Dr Shyamal Banerjee, MD, Professor, Department of Pediatrics, NRS Medical College Hospital, Kolkata, for which he deserves special appreciations. The author expresses his sincere thanks to Professor S Banerjee, DME, Dept. of H&FW, Govt. of West Bengal, Professor (Mrs) M Roy, Principal, Professor PB Chakraborty, MSVP and Professor (Mrs) A Biswas, Head of the Dept., Obs. & Gynae. for their support and encouragement. Mrs Madhusri Konar, MA, BEd deserves full credit for her sincere and patient secretarial job as ever. General Electrical Pvt Ltd is appreciated for the good quality of ultrasonograms. During the production of this textbook, I had the continued assistance and support of a good number of skilled personnel from the publishing house. The author gratefully acknowledges Shri Jitendar P Vij, Group Chairman and Mr Ankit Vij, Group President, Jaypee Brothers Medical Publishers (P) Ltd for their generous support. The author expresses his sincere thanks to Dr Sakshi Arora, Dr Mrinalini Bakshi, Ms Nitasha Arora, along with the entire team of Jaypee Brothers Medical Publishers (P) Ltd, New Delhi for their professional guidance, suggestions and support in bringing out this thoroughly revised eighth edition. I would like to extend my sincere thanks to all the respected teachers and beloved students, who contacted me with their suggestions for the improvement of this book. Their input has been invaluable and is much appreciated. I wish I could acknowledge each one of them in writing. P-13, New CIT Road Hiralal Konar Kolkata – 700 014  Contents Preface..................................................................................................................................................................................... vii-x Acknowledgments............................................................................................................................................................ xi 1 Anatomy of Female Reproductive Organs 1 External Genitalia 1 Internal Genital Organs 4 Muscles and Fascia in relation to the Pelvic Organs 11 Pelvic Floor 11 Perineum 12 Pelvic Fascia 14 Pelvic Cellular Tissue 14 Female Urethra 15 The Urinary Bladder 15 Pelvic Ureter 16 The Breast 16 2 Fundamentals of Reproduction 19 Gametogenesis 19  Oogenesis 19  Spermatogenesis 20 Ovulation 22 Fertilization 23  Morula 24  Blastocyst 25 Implantation 25 Trophoblast 26 The Decidua 27 Chorion and Chorionic Villi 28 Development of Inner Cell Mass 29 Events following Fertilization 30 3 The Placenta and Fetal Membranes 32 The Placenta 32  Development 32  The Placenta at Term 33  Structures 34 Placental Circulation 36 Placental Aging 39 Placental Function 39 The Fetal Membranes 41  Amniotic Cavity, Amnion and Amniotic Fluid 42 The Umbilical Cord 44 4 The Fetus 46 Fetal Physiology 47 The Fetal Circulation 49 Changes of the Fetal Circulation at Birth 50 5 Physiological Changes During Pregnancy 52 Genital Organs 52 Breasts 56 Cutaneous Changes 56 Weight Gain 57 Body Water Metabolism 58 Hematological Changes 58 Cardiovascular System 60 Metabolic Changes 61 Systemic Changes 62 6 Endocrinology in Relation to Reproduction 65 Maturation of Graafian Follicles and Ovulation 65 Maintenance of Corpus Luteum after Fertilization 65 Placental   Endocrinology 66  Protein Hormones 66  Steroidal Hormones 68  Diagnostic Value of Placental Hormones 69 Changes of Endocrine Glands during Pregnancy 70 Maintenance of Lactation 72 xiv Textbook of Obstetrics 7 Diagnosis of Pregnancy 73 First Trimester (First 12 Weeks) 73 Second Trimester (13–28 Weeks) 78 Last Trimester (29–40 Weeks) 80 Differential Diagnosis of Pregnancy 81 Summary of Diagnosis of Pregnancy 82 Chronological Appearance of Specific Symptoms and Signs of Pregnancy 82 Signs of Previous Child Birth 83 Estimation of Gestational Age and Prediction of Expected Date of Delivery 83 Estimation of Fetal Weight 84 8 The Fetus-in-Utero 85 Methods of Obstetrical Examination 87 9 Fetal Skull and Maternal Pelvis 94 Fetal Skull 94 Maternal Pelvis 98    Physiological Enlargement of Pelvis 105 10 Antenatal Care, Preconceptional Counseling and Care 106 Procedure at the First Visit 106 Procedure at the Subsequent Visits 111 Antenatal Advice 112 Minor Ailments in Pregnancy 114 Values of Antenatal Care 116 Preconceptional Counseling and Care 116 11 Antenatal Assessment of Fetal Well-Being 119 Clinical Evaluation of Fetal Well-Being 119 Special Investigations 120 Early Pregnancy 121 Antepartum Fetal Surveillance (Late Pregnancy) 121 Other Investigations in Late Pregnancy 124 12 Prenatal Genetic Counseling, Screening and Diagnosis 127 Prenatal Genetic Screening 127 Prenatal Diagnosis 129 Noninvasive Method of Prenatal Testing 131 13 Normal Labor 134 Causes of Onset of Labor 134 Contractile System of the Myometrium 136 Physiology of Normal Labor 138 Events in First Stage of Labor 140 Events in Second Stage of Labor 143 Events in Third Stage of Labor 143 Mechanism of Normal Labor 145 Anatomy of Labor 149 Clinical Course of First Stage of Labor 151  Second Stage of Labor 153  Third Stage of Labor 154    Place of Delivery 154 Management of Normal Labor 155  First Stage 157  Second Stage 158  Immediate Care of the   Newborn 161  Third Stage 162  Active Management of Third Stage of Labor 164 14 Normal Puerperium 168 Involution of the Uterus 168 Involution of Other Pelvic Structures 170  Lochia 170 General Physiological Changes 171 Lactation 172  Physiology of Lactation 173 Management of Normal Puerperium 174 Management of Ailments 176 Postnatal Care 178 15 Vomiting in Pregnancy 180 Vomiting in Pregnancy 180 Hyperemesis Gravidarum 181 16 Hemorrhage in Early Pregnancy 185 Spontaneous Abortion (Miscarriage) 185    Threatened Miscarriage 187  Inevitable 189  Complete 189  Incomplete 190  Missed 190  Septic Abortion 191  Recurrent 195 Cervical Incompetence 197 Induction of Abortion 202 Medical Termination of Pregnancy (MTP) 202 Methods of Termination of Pregnancy 203  First Trimester 203  Mid Trimester 204  Medical   Methods 204  Surgical Methods 205  Complications of MTP 206  Contents xv Ectopic   Pregnancy 207  Tubal 208  Unruptured Tubal Ectopic Pregnancy 211  Chronic or Old Ectopic 212  Interstitial Pregnancy 214 Abdominal Pregnancy 218 Ovarian Pregnancy 220 Cornual Pregnancy 220 Cervical Pregnancy 220 Gestational Trophoblastic Diseases (GTD) 221 Hydatidiform Mole 222 Partial or Incomplete Mole 230 Placental Site Trophoblastic Tumor (PSTT) 231 Persistent Gestational Trophoblastic Disease 231 17 Multiple Pregnancy, Amniotic Fluid Disorders, Abnormalities of Placenta and Cord 233 Twins 233 Triplets, Quadruplets 244 Amniotic Fluid Disorders 246  Polyhydramnios 246  Oligohydramnios 250 Abnormalities of Placenta and Cord 251 18 Hypertensive Disorders in Pregnancy 255 Preeclampsia   256  Etiopathogenesis 257  Pathophysiology 258  Clinical Types 260  Clinical Features 261  Complications 263  Prophylactic Measures 264  Management 264  Acute Fulminant Preeclampsia 267 Eclampsia 268  Clinical Features of Eclampsia 270  Management 271   Gestational Hypertension 276 Chronic Hypertension 277 Essential Hypertension 277 Chronic Renal Diseases in Pregnancy 278 19 Antepartum Hemorrhage 282 Placenta   Previa 282  Clinical Features 284  Placentography 286  Differential Diagnosis 287 Complications 288  Management 289  Practical Guideline for Cesarean Delivery 291  Practical  Guide to Lower Segment Approach for Placenta Previa 293  Practical Guidelines to Lower Segment Approach for Placenta Previa Accreta 293 Abruptio Placentae 294  Clinical Features 297  Complications 297  Treatment 299   Indeterminate Bleeding 301 20 Medical and Surgical Illness Complicating Pregnancy 303 Hematological   Disorders in Pregnancy 303  Anemia in Pregnancy 303  Hemoglobinopathies 316 Sickle Cell Hemoglobinopathies 316  Thalassemia Syndromes 317  Platelet Disorders 318  Heart Disease in Pregnancy 319 Diabetes Mellitus and Pregnancy 325  Gestational Diabetes Mellitus (GDM) 326  Overt Diabetes 327   Thyroid Dysfunction and Pregnancy 334 Jaundice in Pregnancy 335  Cholestasis 336 Viral Hepatitis 336 Epilepsy in Pregnancy 338 Asthma in Pregnancy 339 Systemic Lupus Erythematosus (SLE) 340 Tuberculosis in Pregnancy 341 Syphilis in Pregnancy 342 Parasitic and Protozoal Infestations in Pregnancy 344  Malaria 344  Toxoplasmosis 345    Listeriosis 346  Intestinal Worms 346 Pyelonephritis in Pregnancy 346 Asymptomatic Bacteriuria (ASB) 347 Viral Infections in Pregnancy 348  Rubella 348  Measles 349  Influenza 349  Chickenpox   (Varicella) 349  Cytomegalovirus (CMV) 349  Parvoviruses 349  Mumps (RNA) 350  Herpes Simplex (DNA) Virus (HSV) 350  Dengue 350 Human Immunodeficiency Virus Infection (HIV ) and Acquired Immunodeficiency Syndrome (AIDS) 350 Surgical Illness during Pregnancy 353 Acute Pain in Abdomen during Pregnancy 355 21 Gynecological Disorders in Pregnancy 356 Abdominal Vaginal Discharge 356 Congenital Malformation 356 Carcinoma Cervix with Pregnancy 357 Leiomyomas with Pregnancy 359 Ovarian Tumor in Pregnancy 360 Retroverted Gravid Uterus 361 Morbid Anatomic Changes if Left Uncared for 362 Genital Prolapse in Pregnancy 363 xvi Textbook of Obstetrics 22 Preterm Labor, Preterm Rupture of the Membranes, Postmaturity, 365 Intrauterine Fetal Death Preterm Labor 365 Prelabor Rupture of the Membrane (PROM) 369 Management 369 Prolonged and Post-term Pregnancy 371 Intrauterine Fetal Death (IUFD) 375 23 Complicated Pregnancy 381 Pregnancy   with Prior Cesarean Delivery 381  Integrity of the Scar 381  Evidences of Scar Rupture (or Scar Dehiscence) during Labor 383  Management of a Pregnancy with Prior Cesarean Delivery 383  Vaginal Birth After Previous Cesarean (VBAC) 384 Pregnancy in a Rh-negative Woman 386  Red Cell Alloimmunization 387  Fetal Affection   by the Rh-antibody 388  Manifestations of the Hemolytic Disease of the Fetus and Newborn (HDFN) 388  Prevention of Rh-immunization 389  Antenatal Investigation Protocol of Rh-negative Mothers 391  Plan of Delivery 393 Exchange Transfusion in the Newborn 396  Prognosis 397 Elderly Primigravida 398 Grand Multipara 398 Bad Obstetric History (BOH) 399 Obesity in Pregnancy 400 24 Contracted Pelvis 402 Valiation of Female Pelvis 402 Asymmetrical or Obliquely Contracted Pelvis 405 Mechanism of Labor in Contracted Pelvis with Vertex Presentation 405 Diagnosis of Contracted Pelvis 406 Disproportion 409  Diagnosis of Cephalopelvic Disproportion (CPD) 410  Effects of Contracted   Pelvis on Pregnancy and Labor 412  Management 412 Trial Labor 412 Midpelvic and Outlet Disproportion 414 25 Abnormal Uterine Action 415 Types 415 Uterine Inertia 416 Incoordinate Uterine Action 417 Spastic Lower Segment 418 Constriction Ring 419 Cervical Dystocia 419 Generalized Tonic Contraction 419 Precipitate Labor 420 Tonic Uterine Contraction and Retraction 420 Summary 423 26 COMPLICATED LABOR-Malposition, Malpresentation and Cord Prolapse 424 Occiput-Posterior Position (OP) 424 Arrested Occipitoposterior Position 430 Deep Transverse Arrest (DTA) 431 Manual Rotation for Occipitoposterior Position 431 Breech Presentation 434 Antenatal Management 439 Management of Vaginal Breech Delivery 441 Assisted Breech Delivery 442 Management of Complicated Breech 446 Face Presentation 449 Brow Presentation 453 Transverse Lie 454 Unstable Lie 459 Compound Presentation 459 Cord Prolapse 460 27 Prolonged Labor, Obstructed Labor, Dystocia Caused by Fetal Anomalies 463 Prolonged Labor 463 Obstructed Labor 467 Dystocia Caused by Fetal Anomalies 468 Shoulder Dystocia 469  Hydrocephalus 470  Neural Tube Defects 471  Enlargement of Fetal   Abdomen 472  Monsters 472  Conjoined Twins 473 28 Complications of the Third Stage of Labor 474 Postpartum Hemorrhage (PPH) 474 Primary Postpartum Hemorrhage 475  Management of Third Stage Bleeding 477    Steps of Manual Removal of Placenta 478  Secondary Postpartum Hemorrhage 483 Retained Placenta 484 Placenta Accreta 486 Inversion of the Uterus 487 29 Injuries to the Birth Canal 489 Vulva 489 Perineum 489 Vagina 491 Cervix 491 Pelvic Hematoma 492 Rupture of the Uterus 493 Visceral Injuries 499  Contents xvii 30 Abnormalities of the Puerperium 500 Puerperal Pyrexia 500 Puerperal Sepsis 500 Subinvolution 505 Urinary Complications 505 Breast Complications 506 Puerperal Venous Thrombosis and Pulmonary Embolism 508 Pulmonary Embolism (PE) 510 Obstetric Palsies 511 Puerperal Emergencies 511 Psychiatric Disorders during Puerperium 512 Psychological Response to Perinatal Deaths and Management 513 31 The Term Newborn Infant 514 Physical Features of the Newborn 514 Immediate Care of the Newborn 517 Infant Feeding 519  Breastfeeding 519  Artificial Feeding 524 Childhood Immunization Program 526 32 Low Birth Weight Baby 527 Preterm Baby 528 Fetal Growth Restriction (FGR) 533 33 Disease of the Fetus and the Newborn 541 Perinatal Asphyxia 541 Fetal Respiration 541 Respiratory Distress in the Newborn 547  Idiopathic Respiratory Distress Syndrome 547  Meconium   Aspiration Syndrome (MAS) 550 Jaundice of the Newborn 551  Hyperbilirubinemia of the Newborn 552  Kernicterus 553 Hemolytic Disease of the Newborn 554  ABO Group Incompatibility 555 Bleeding Disorders in the Newborn 555 Anemia in the Newborn 556 Seizures in Newborn 557 Birth Injuries of the Newborn 558  Intracranial Hemorrhage (ICH) 559 Other Injuries 561 Perinatal Infections 563 Ophthalmia Neonatorum (Conjunctivitis) 564 Skin Infections 565 Necrotizing Enterocolitis 566 Mucocutaneous Candidiasis 567 Congenital Malformations and Prenatal Diagnosis 567 Down’s Syndrome (Trisomy 21) 568 Congenital Malformations in Newborn and the Surgical Emergencies 569 Nonimmune Fetal Hydrops (NIFH) 571 34 Pharmacotherapeutics in Obstetrics 573 Oxytocics   in Obstetrics 573  Oxytocin 573  Ergot Derivatives 577  Prostaglandins (PGS) 578 Antihypertensive Therapy 581 Diuretics 582 Tocolytic Agents 583 Anticonvulsants 584 Anticoagulants 585 Maternal Drug Intake and Breastfeeding 586 Fetal Hazards on Maternal Medication during Pregnancy 587 Analgesia and Anesthesia in Obstetrics 590  Anatomical and Physiological Considerations 590    Analgesia during Labor and Delivery 591  Sedatives and Analgesics 592  Inhalation Methods 592  Regional (Neuraxial) Anesthesia 593  Infiltration Analgesia 595  General Anesthesia for Cesarean Section 596 35 Induction of Labor 598 Indications and Contraindications 598 Parameters to Assess Prior to Induction 599 Methods of Cervical Ripening 599 Methods of Induction of Labor 600  Medical 600  Surgical 601  Combined 604 Active Management of Labor 605 Partograph 607 36 Population Dynamics and Control of Conception 609 Population Dynamics 609 Control of Conception 610 Contraception 610  Method 611  Barrier Methods 611  Natural Contraception 614  Intrauterine   Contraceptive Devices (IUCDs) 615  Steroidal Contraceptions 621  Combined Oral Contraceptives (Pills) 622  Injectable Progestins 628  Implant 628  Emergency Contraception (EC) 629  Sterilization 631  Vasectomy 631  Female Sterilization 632  Laparoscopic Sterilization 635  Contraceptive 637  Contraceptive Counseling and Prescription 637 Ongoing Trials and Selective Availability 638  Centchroman Prescription 638  Combined Injectable   Contraceptives 639  Biodegradable Implants 639  Newer IUDs 639 xviii Textbook of Obstetrics 37 Operative Obstetrics 642 Dilatation and Evacuation 642 Management Protocol of Uterine Perforation 645 Suction Evacuation 645 Menstrual Regulation 646 Manual Vacuum Aspiration 646 Hysterotomy 647 Episiotomy 647 Operative Vaginal Delivery 651 Forceps 651 Ventouse 660 Version 663  External Cephalic Version 663  Internal Version 665  Bipolar Version 666 Destructive Operations 666  Craniotomy 666  Decapitation 668  Evisceration 668  Cleidotomy 668    Postoperative Care Following Destructive Operations 669 Cesarean Section (CS) 669  Lower Segment 671  Classical 676  Complication of Cesarean   Section 677 Measures to Reduce Cesarean Births 679 Symphysiotomy 679 38 Safe Motherhood, Epidemiology of Obstetrics 680 Safe Motherhood 680 Obstetric Care and the Society 681 Reproductive and Child Health (RCH) Care 681 Epidemiology of Obstetrics 683 Maternal Mortality 683 Maternal Near Miss 687 Maternal Morbidity 687 Perinatal Mortality 687 Stillbirths 690 Neonatal Deaths 690 Women’s Health (MDGs) Beyond 2015; 690 39 Special Topics in Obstetrics 692 Intrapartum   Fetal Monitoring 692  Electronic Fetal Monitoring 693  Nonreassuring Fetal Status (NRFS) 697 Shock in Obstetrics 699  Classification 702  Hemorrhagic Shock 704  Endotoxic Shock 705 Acute Kidney Injury (AKI) 706 Blood Coagulation Disorders in Obstetrics 711 High-risk Pregnancy 716 Immunology in Obstetrics 719 Critical Care in Obstetrics 722 ICU 723 40 Current Topics in Obstetrics 726 Antibiotic Prophylaxis in Cesarean Section 726 Day Care Obstetrics 726 Legal and Ethical Issues in Obstetric Practice 727 Audit In Obstetrics 728 The Preconception and Prenatal Diagnostic Techniques and PNDT Act 729 Umbilical Cord Blood Banking 729 Stem Cells and Therapies in Obstetrics 730 41 Imaging in Obstetrics (USG, MRI, CT, Radiology), Amniocentesis and 732 Guides to Clinical Tests Ultrasound   In Obstetrics 732  Three-dimensional Ultrasonography (3D Scanning) 733  First Trimester 734  Midtrimester 735  Doppler 737  Third Trimester 739 Magnetic Resonance Imaging (MRI) in Obstetrics 739 Computed Tomography (CT) 740 Radiology in Obstetrics 740 Amniocentesis 741 Guides to Clinical Tests 742  Urine 742  Tests for Blood Coagulation Disorders 743  Collection of   Blood Sample 744  Cervical and Vaginal Cytology 746 42 Practical Obstetrics 747 Clinical Thermometer 747 Obstetric Instruments 747 Specimens 758 Imaging Studies (USG Plates) 759 Processing of Instruments 763 Oxytocics: Oxytocin, Methergin, Misoprostol (PGE1); Carboprost (PGF2a), Prostin (PGE2) 764 Doppler (Ultrasound) Fetal Monitor 764 Index........................................................................................................................................................................................ 765  Abbreviations AC : Abdominal Circumference CDC : Center for Disease Control aCL : anti-Cardiolipin Antibodies CH : Crown Heel ACOG : American College of Obstetricians CIN : Cervical Intraepithelial Neoplasia and Gynecologists CIRCI : Critical Illness-related Corticosteroid AFI : Amniotic Fluid Index Insufficiency AFP : Alpha Fetoprotein CMQCC : California Maternal Quality Care AFV : Amniotic Fluid Volume Collaboration AGS : Antigas Gangrene Serum CO : Cardiac Output ALT : Alanine Amniotransferase COCs : Combined Oral Contraceptives AMTSL : Active Management of Third Stage of COX : Cyclo-oxygenase Labor CPAP : Continuous Positive Airway Pressure AN : Atrial Natriuretic Factor CPD : Cephalopelvic Disproportion APH : Antepartum Hemorrhage CPK : Creatinine Phosphokinase aPLs : anti-Phospholipid Antibodies CPT : Complete Perineal Tear APTT : Activated Partial Thromboplastin CRH : Corticotrophin-releasing Hormone Time CRL : Crown Rump Length ARDS : Acute Respiratory Distress Syndrome CRP : C-Reactive Protein ARM : Artificial Rupture of Membranes CRS : Congenital Rubella Syndrome ART : Assisted Reproductive Technology CS : Cesarean Section ASD : Atrial Septal Defect CSE : Combined Spinal Epidural AST : Aspartate Amniotransferase CST : Contraction Stress Test ATP : Adenosine Triphosphate CT : Computed Tomography ATS : Anti-Tetanus Serum CTG : Cardiotocography AUA : Abnormal Uterine Action CTPA : Computed Tomographic Pulmonary β2GP-1 : β2 Glycoprotein-1 Angiography BMI : Body Mass Index CVP : Central Venous Pressure BPD : Biparietal Diameter CVS : Chorionic Villus Sampling BPD : Broncho-pulmonary Dysplasia CVS : Congenital Vericella Syndrome BPP : Biophysical Profile CXR : Chest X-ray CBG : Corticosteroid-binding Globulin D/D : Diamniotic-Dichorionic CCF : Congestive Cardiac Failure D/M : Diamniotic-Monochorionic xx Textbook of Obstetrics D&E : Dilatation and Evacuation GLUT : Glucose Transporter DBP : Diastolic Blood Pressure GLUT-1 : Glucose Transporter-1 DFMC : Daily Fetal Movement Counting GnRH : Gonadotropin-releasing Hormone DIC : Disseminated Intravascular GTN : Gestational Trophoblastic Neoplasia Coagulopathy GTN : Glyceryl Trinitrate DIPSI : Diabetes in Pregnancy Study Group GTT : Glucose Tolerance Test India HAART : Highly Active Anti-retroviral Therapy DMPA : Depot Medroxy Progesterone Acetate Hb : Hemoglobin DTA : Deep Transverse Arrest HC : Head Circumference DV : Ductus Venosus hCG : Human Chorionic Gonadotropin DVT : Deep Vein Thrombosis HCS : Hemopoietic Stem Cells EFM : Electronic Fetal Monitoring hCT : Human Chorionic Thyrotropin EACA : Epsilon Amino Caproic Acid HDFN : Hemolytic Disease of the Fetus and EAS : External Anal Sphincter Newborn ECG : Electro Cardiography HDL : High Density Lipoprotein ECV : External Cephalic Version HELLP : Hemolysis, Elevated Liver Enzymes, EDD : Expected Date of Delivery Low Platelet EFM : Electronic Fetal Monitoring HIE : Hypoxic Ischemic Encephalopathy EGN : Etonogestrel HIV : Human Immunodeficiency Virus EmOC : Emergency Obstetric Care HLA : Human Leucocyte Antigen EmONC : Emergency Obstetric and Newborn HMD : Hyaline Membrane Disease Care HPL : Human Placental Lactogen EPF : Early Pregnancy Factor HR : Heart Rate ERPC : Evacuation of Retained Products of IAS : Internal Anal Sphincter Conception ICA : Incordinate Uterine Action ES : Embryonic Stem ICH : Intracranial Hemorrhage FBS : Fetal Blood Sampling ICOG : Indian College of Obstetricians & FDP : Fibrin Degradation Products Gynaecologists FFA : Free Fatty Acid IFM : Intrapartum Fetal Monitoring ffDNA : free fetal DNA IGF-1 : Insulin Growth Factor-1 FFP : Fresh Frozen Plasma IgG : Immunoglobulin G FGR : Fetal Growth Restriction IOL : Induction of Labour FHR : Fetal Heart Rate IPT : Intraperitoneal Transfusion FHS : Fetal Heart Sound ITU : Intensive Care Unit FIGO : International Federation of IUD : Intrauterine Device Gynecology and Obstetrics IUCD : Intrauterine Contraceptive Device FISH : Fluorescence in situ Hybridization IUFD : Intrauterine Fetal Death FL : Femur Length IUGR : Intrauterine Growth Restriction FMH : Fetomaternal Hemorrhage IUT : Intrauterine Transfusion FRU : First Referral Unit IVC : Inferior Vena Cava FSH : Follicle-stimulating Hormone IVH : Intraventricular Hemorrhage GA : Gestational Age IVIg : Intravenous Immunoglobulin GBS : Group B Streptococcus IVT : Intravascular Transfusion GDM : Gestational Diabetes Mellitus JSY : Janani Suraksha Yojana  Abbreviations xxi KB : Kleihauer-Betke NST : Non-stress Test L : S Ratio : Lecithin-Sphingomyelin Ratio NSV : No-Scalpel Vasectomy L/S : Lecithin/Sphingomyelin NT : Nuchal Translucency LA : Lupus Anticoagulant NTD : Neural Tube Defect LAM : Lactational Amenorrhoea OA : Occiput Anterior LBW : Low Birth Weight OGN : Oestrogen LDH : Lactic Dehydrogenase OP : Occiput Posterior LDL : Low Density Lipoprotein OT : Operation Theatre LGA : Large for Gestational Age PAPP-A : Pregnancy-associated Plasma Protein-A LH : Luteinizing Hormone PBI : Protein-bound Iodine LMA : Left Mentoanterior PCA : Patient-controlled Analgesia LMP : Last Menstrual Period PCOS : Polycystic Ovarian Syndrome LMWH : Low Molecular Weight Heparin PCR : Polymerase Chain Reaction LNG-IUS : Levonorgestrel-Intrauterine System PCWP : Pulmonary Capillary Wedge Pressure LOA : Left Occiput Anterior PDA : Patent Ductus Arteriosus LOP : Left Occiput Posterior PDS : Poly Dioxanone LOT : Left Occiput Transverse PE : Pulmonary Embolism LPD : Luteal Phase Defect PG : Phosphatidyglycerol LSA : Left Sacrum Anterior PGD : Preimplantation Genetic Diagnosis LSCS : Lower Segment Cesarean Section PGN : Progestin LVP : Largest Vertical Pocket PGs : Prostaglandins M/M : Monoamniotic-Monochorionic PI : Pulsality Index MAP : Mean Arterial Pressure PID : Pelvic Inflammatory Disease MCA : Middle Cerebral Artery PIH : Pregnancy Induced Hypertension MCU : Microcirculatory Unit PO : Per Oral MDGs : Millennium Development Goals POD : Pouch of Douglas MFMU : Maternal Fetal Medicine Unit POP : Persistent Occiput Posterior MLCK : Myocin Light Chain Kinase PPBs : Postprandial Blood Sugar MMR : Maternal Mortality Ratio PPH : Postpartum Haemorrhage MOMs : Multiples of the Medians PRES : Posterior Reversible Encephalopathy MRA : Magnetic Resonance Angiography Syndrome MRI : Magnetic Resonance Imaging PROM : Prelabour Rupture of Membranes MSAFP : Maternal Serum Alphafeto Protein PSV : Peak Systolic Velocity MVA : Manual Vacuum Aspiration PT : Prothrombin Time NEC : Necrotising Enterocolitis PTB : Preterm Birth NICE : National Institute of Clinical PTH : Parathyroid Hormone Excellence PVL : Periventricular Leukomalacia NICHD : National Institute of Child Health and PVP : Pulmonary Vascular Resistance Development RAAS : Renin Angiotensin Aldosterone NICU : Neonatal Intensive Care Unit System NK : Natural Killer Cells RBC : Red Blood Cells NO : Nitric Oxide RCOG : Royal College of Obstetricians and NPN : Non-Protein Nitrogen Gynaecologists NRFS : Non-reassuring Fetal Status RDS : Respiratory Distress Syndrome xxii Textbook of Obstetrics RhIg : Rhesus Immunoglobulin TBG : Thyroxin Binding Globulin RI : Resistance Index TC : Transcervical RNTCR : Revised National Tuberculosis Control TDI : Total Dose Infusion Programme TDO : Transverse Diameter of the Outlet ROA : Right Occiput Anterior TGFβ : Transforming Growth Factor β ROP : Right Occiput Posterior TNFα : Tumour Necrosis Factor-α ROS : Reactive Oxygen Species TOLAC : Trial of Labour After Caesarean ROT : Right Occiput Transverse TPS : Trans perineal Sonography RR : Respiratory Rate TRAP : Twin Reverse Arterial Perfusion RSP : Right Sacro Posterior TTTS : Twin to Twin Transfusion Syndrome SC : Sub Cutaneous TVS : Trans Vaginal Sonography SBP : Systolic Blood Pressure UE3 : Unconjugated Estriol SCJ : Squamocolumnar Junction USG : Ultrasonogrpahy SFH : Symphysis Fundal Height UTI : Urinary Tract Infection SGA : Small for gestational Age UV : Umbilical Vein SIRS : Systemic Inflammatory Response V/Q : Ventilation/Perfusion Ratio Syndrome VBAC : Vaginal Birth After Cesarean SLE : Systemic Lupus Erythematosus VBAC-TOL : VBAC-Trial of Labor SMI : Safe Motherhood Initiative VEGF : Vascular Endothelial Growth Factor SV : Stroke Volume VSD : Ventricular Septal Defect SVD : Systemic Vascular Resistance VUS : Venous Ultrasonography TA : Transabdominal VVF : Vesico Vaginal Fistula TAS : Transabdominal Sonography WHO : World Health Organization  Chapter 1 Anatomy of Female Reproductive Organs 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’s glands and vestibular bulbs (Fig. 1.1). It is 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. MONS VENERIS (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. 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. LABIA MINORA: 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 fossa navicularis. The labia minora contain no hair follicles or sweat glands. The folds contain connective tissues, numerous sebaceous glands, erectile muscle fibers and numerous 2 Textbook of Obstetrics vessels and nerve endings. The labia minora are homologous to the penile urethra and part of the skin of penis in males. 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 under surface of the symphysis pubis by the suspensory ligament. 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. Fig. 1.1: The virginal vulva (c) Opening of Bartholin’s ducts: There are two Bartholin glands (greater vestibular gland), one on each side. They are situated in the superficial perineal pouch, close to the posterior end of the vestibular  Chapter 1 Anatomy of Female Reproductive Organs 3 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-third 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) Skene’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 and corpus spongiosum in the male. They are likely to be injured during childbirth with brisk hemorrhage (Fig. 1.2). Fig. 1.2: Exposition of superficial perineal pouch with vestibular bulb and Bartholin’s gland PERINEUM: The details of its anatomy are described later in the chapter. BLOOD SUPPLY: Arteries—(a) Branches of internal pudendal 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 pudendal. 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— (a) anterosuperior part is supplied by the cutaneous branches from the ilioinguinal and genital branch of genitofemoral nerve 4 Textbook of Obstetrics (L1 and L2) and the posteroinferior part by the pudendal branches from the posterior cutaneous nerve of thigh (S1.2.3). Between these two groups, the vulva is supplied by the labial and perineal branches of the pudendal 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 GENITAL ORGANS 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. 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. Fig. 1.3: Midsagittal section of the female pelvis showing relative position of the pelvic organs  Chapter 1 Anatomy of Female Reproductive Organs 5 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 artery 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 Döderlein’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. BLOOD SUPPLY: The arteries involved are—(1) Cervicovaginal branch of the uterine artery, (2) vaginal artery—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 4/5th, 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 Müllerian ducts. (b) Lower 1/5th, 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. THE 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. 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 gm to 80 gm. It has got the following parts: 6 Textbook of Obstetrics 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 Fig. 1.4: Coronal section showing different parts of uterus 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 6.5–7 cm. 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 artery 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). Fig. 1.5: The relation of the ureter to the uterine artery STRUCTURES Body — The wall consists of three layers from outside inwards: — 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.  Chapter 1 Anatomy of Female Reproductive Organs 7 — 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. — Endometrium: The mucous 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. Cervix—The cervix is composed mainly of fibrous connective 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 surface 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 posterior walls of the uterus and upper one-third of the posterior vaginal wall where 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 the Figures 1.6A and B. A B Figs 1.6A and B: (A) Showing pattern of basal and spiral arteries in the endometrium; (B) Internal blood supply of uterus 8 Textbook of Obstetrics 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 and T6 (motor) and T10 to L1 spinal segments (sensory). The somatic distribution of uterine pain is that area of the abdomen supplied by T10 to L8. The parasympathetic system is represented on either side by the pelvic nerve which consists of both motor and sensory fibers from S2, S3, S4 and ends in the ganglia of Frankenhauser. The details are described in Chapter 33. 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 Müllerian ducts. FALLOPIAN TUBE (Synonyms: Uterine tube, oviduct) The uterine tubes are paired structures, measuring about 10 cm and are situated in the medial three-fourth 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. 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 of 6 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. 1.7). 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, (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 mucosal 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, (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.  Chapter 1 Anatomy of Female Reproductive Organs 9 Fig. 1.7: Half of uterine cavity and fallopian tube of one side are cut open to show different parts of the tube. The vestigial structures in the broad ligament are shown NERVE SUPPLY: The nerve supply is derived from the uterine and ovarian nerves. The tube is very much sensitive to handling. DEVELOPMENT: The tube is developed from the upper vertical part of the corresponding Müllerian duct at about 6–10th week. THE OVARY The ovaries are paired sex glands or gonads in female which are concerned for (i) germ cell maturation, storage and its release and (ii) steroidogenesis. Each gland is oval in shape and pinkish gray in color and the surface is scarred during reproductive period. It measures about 3 cm in length, 2 cm in breadth and 1 cm in thickness. Each ovary presents two ends—tubal and uterine, two borders—mesovarium and free posterior and two surfaces—medial and lateral. The ovaries are intraperitoneal structures. In nullipara, the ovary lies in the ovarian fossa on the lateral pelvic wall. The ovary is attached to the posterior layer of the broad ligament by the mesovarium, to the lateral pelvic wall by the infundibulopelvic ligament and to the uterus by the ovarian ligament. RELATIONS: Mesovarium or anterior border—A fold of peritoneum from the posterior leaf of the broad ligament is attached to the anterior border through which the ovarian vessels and nerves enter the hilum of the gland. Posterior border is free and is related to the tubal ampulla. It is separated by the peritoneum from the ureter and the internal iliac artery. Medial surface is related to fimbrial part of the tube. Lateral surface is in contact with the ovarian fossa on the lateral pelvic wall. The fossa is related superiorly to the external iliac vein, posteriorly to the ureter and internal iliac vessels and laterally to the peritoneum separating the obturator vessels and nerves (Fig. 1.8). STRUCTURES: The ovary is covered by a single layer of cubical cell known as germinal epithelium. The substance of the gland consists of outer cortex and inner medulla. Cortex—It consists of stromal cells which are thickened beneath the germinal epithelium to form tunica albuginea. During reproductive period (i.e., from puberty to menopause) the cortex is studded with numerous follicular structures, called the functional units of the ovary, in various phases of their development. These are related to sex hormone production and ovulation. The structures include— 10 Textbook of Obstetrics Fig. 1.8: The ovarian fossa with the structures in the lateral pelvic wall primordial follicles, maturing follicles, Graafian follicles and corpus luteum. Atresia of the structures results in formation of atretic follicles or corpus albicans (Fig. 1.9). Medulla—It consists of loose connective tissues, few unstriped muscles, blood vessels and nerves. There is a small collection of cells called “hilus cells” which are homologous to the interstitial cells of the testes. Fig. 1.9: Histological structure of the ovary  Chapter 1 Anatomy of Female Reproductive Organs 11 BLOOD SUPPLY: Arterial supply is from the ovarian artery, a branch of the abdominal aorta. Venous drainage is through pampiniform plexus, to form the ovarian veins which drain into inferior vena cava on the right side and left renal vein on the left side. Part of the venous blood from the placental site drains into the ovarian veins and thus may become the site of thrombophlebitis in puerperium. LYMPHATICS: Through the ovarian vessels drain to the para-aortic lymph nodes. NERVE SUPPLY: Sympathetic supply comes down along the ovarian artery from T10 segment. Ovaries are sensitive to manual squeezing. DEVELOPMENT: The ovary is developed from the cortex of the undifferentiated genital ridges by about 9th week; the primary germ cells reaching the site migrating from the dorsal end of yolk sac. MUSCLES AND FASCIA IN RELATION TO THE PELVIC ORGANS The most important muscle supporting the pelvic organs is the levator ani which forms the pelvic floor. The small muscles of the perineum also have got some contribution. PELVIC FLOOR (Synonym: Pelvic diaphragm) Pelvic floor is a muscular partition which separates the pelvic cavity from the anatomical perineum. It consists of three sets of muscles on either side—pubococcygeus, iliococcygeus and ischiococcygeus and these are collectively called levator ani. Its upper surface is concave and slopes downwards, backwards and medially and is covered by parietal layer of pelvic fascia. The inferior surface is convex and is covered by anal fascia. The muscle with the covering fascia is called the pelvic diaphragm. ORIGIN: Each levator ani arises from the back of the pubic rami, from the condensed fascia covering the obturator internus (white line) and from the inner surface of the ischial spine. INSERTION: From this extensive origin, the fibers pass, backwards and medially to be inserted in the midline from before backwards to the vagina (lateral and posterior walls), perineal body and anococcygeal raphe, lateral borders of the coccyx and lower part of the sacrum (Fig. 1.10). Fig. 1.10: Levator ani muscles viewed from above 12 Textbook of Obstetrics GAPS: There are two gaps in the midline—(1) The anterior one is called hiatus urogenitalis which is bridged by the muscles and fascia of urogenital triangle and pierced by the urethra and vagina. (2) The posterior one is called hiatus rectalis, transmitting the rectum. STRUCTURES IN RELATION TO PELVIC FLOOR The superior surface is related with the following: (1) Pelvic organs from anterior to posterior are bladder, vagina, uterus and rectum. (2) Pelvic cellular tissues between the pelvic peritoneum and upper surface of the levator ani which fill all the available spaces. (3) Ureter lies on the floor in relation to the lateral vaginal fornix. The uterine artery lies above and the vaginal artery lies below it. (4) Pelvic nerves. The inferior surface is related to the anatomical perineum. NERVE SUPPLY: It is supplied by the 4th sacral nerve, inferior rectal nerve and a perineal branch of pudendal nerve S2,3,4. FUNCTIONS: (1) To support the pelvic organs—The pubovaginalis which forms a “U” shaped sling, supports the vagina which in turn supports the other pelvic organs— bladder and uterus. Weakness or tear of this sling during parturition is responsible for prolapse of the organs concerned. (2) To maintain intra-abdominal pressure by reflexly responding to its changes. (3) Facilitates anterior internal rotation of the presenting part when it presses on the pelvic floor. (4) Puborectalis plays an ancillary role to the action of the external anal sphincter. (5) Ischiococcygeus helps to stabilize the sacroiliac and sacrococcygeal joints. (6) To steady the perineal body. PELVIC FLOOR DURING PREGNANCY AND PARTURITION: During pregnancy levator muscles undergo hypertrophy, become less rigid and more distensible. Due to water retention, it swells up and sags down. In the second stage, the pubovaginalis and puborectalis relax and the levator ani is drawn up over the advancing presenting part in the second stage. Failure of the levator ani to relax at the crucial moment may lead to extensive damage of the pelvic structures. The effect of such a displacement is to elongate the birth canal which is composed solely of soft parts below the bony outlet. The soft canal has got deep lateral and posterior walls and its axis is in continuation with the axis of the bony pelvis. PERINEUM ANATOMICAL PERINEUM: Anatomically, the perineum is bounded above by the inferior surface of the pelvic floor, below by the skin between the buttocks and thighs. Laterally, it is bounded by the ischiopubic ramus, ischial tuberosities and sacrotuberous ligaments and posteriorly, by the coccyx. The diamond shaped space of the bony pelvic outlet is divided into two triangular spaces with the common base formed by the free border of the urogenital diaphragm. The anterior triangle is called the urogenital triangle which fills up the gap of the hiatus urogenitalis and is important from the obstetric point of view. The posterior one is called the anal triangle. Urogenital triangle: It is pierced by the terminal part of the vagina and the urethra. The small perineal muscles are situated in two compartments formed by the ill-defined fascia. The compartments are superficial and deep perineal pouch. The superficial pouch is formed by the deep layer of the superficial perineal fascia (Colles fascia) and inferior layer of the urogenital diaphragm (perineal membrane). The contents are (Fig. 1.2) superficial transverse perinei (paired), bulbospongiosus covering the bulb of the vestibule, ischiocavernosus (paired) covering the crura of the clitoris and the Bartholin’s gland (paired). The deep perineal pouch is formed by the inferior and superior layer of the urogenital diaphragm—together called urogenital diaphragm or triangular ligament. Between  Chapter 1 Anatomy of Female Reproductive Organs 13 Fig. 1.11: Schematic diagram showing the pelvic muscles, fascia and cellular tissue as seen from the front the layers there is a potential space of about 1.25 cm. The contents are the following muscles—deep transverse perinei (paired) and sphincter urethrae membranaceae. Both the pouches contain vessels and nerves (Fig. 1.11). Anal triangle: It has got no obstetric importance. It contains the terminal part of the anal canal with sphincter ani externus, anococcygeal body, ischiorectal fossa, blood vessels, nerves and lymphatics. OBSTETRICAL PERINEUM: (Synonyms: Perineal body, central point of the perineum). The pyramidal shaped tissue where the pelvic floor and the perineal muscles and fascia meet in between the vagina and the anal canal is called the obstetrical perineum. It measures about 4 cm × 4 cm with the base covered by the perineal skin and the apex is pointed and is continuous with the rectovaginal septum. The musculofascial structures involved are: Fasciae—(1) Two layers of superficial perineal fascia-superficial fatty layer and deeper layer called Colles fascia. (2) Inferior and superior layer of urogenital diaphragm, together called triangular ligament. Muscles—(1) Superficial and deep transverse perinei (paired). (2) Bulbospongiosus. (3) Levator ani-pubococcygeus part (paired), situated at the junction of the upper two-third and lower one- third of the vagina. (4) Sphincter ani externus (few fibers). Importance: (1) It helps to support the levator ani which is placed above it. (2) By supporting the posterior vaginal wall, it indirectly supports the anterior vaginal wall, bladder and the uterus. (3) It is vulnerable to injury during childbirth. (4) Deliberate cutting of the structures during delivery is called episiotomy. 14 Textbook of Obstetrics PELVIC FASCIA For descriptive purpose, the pelvic fascia is grouped under the heading that covers the pelvic wall, the pelvic floor and the pelvic viscera. Fascia on the pelvic wall: It is very tough and membranous. It covers the obturator internus and pyriformis and gets attached to the margins of the bone. The pelvic nerves lie external to the fascia but the vessels lie internal to it. Fascia on the pelvic floor: It is not tough but loose. The superior and the inferior surfaces are covered by the parietal layer of the pelvic fascia which runs down from the white line to merge with the visceral layer of the pelvic fascia covering the anal canal (Fig. 1.11). Fascia covering the pelvic viscera: The fascia is not condensed and often contains loose areolar tissue to allow distension of the organs. PELVIC CELLULAR TISSUE It lies between the pelvic peritoneum and the pelvic floor and fills up all the available empty spaces. It contains fatty and connective tissues and unstriated muscle fibers. Its distribution around the vaginal vault, supravaginal part of the cervix and into the layers of the broad ligament is called parametrium. Condensation occurs especially near the cervicovaginal junction to form ligaments which extend from the viscera to the pelvic walls on either side. These are Mackenrodt’s ligaments, uterosacral ligaments and vesicocervical ligaments (fascia). All these constitute important supports of the uterus to keep it in position (Fig. 1.12). Importance: (1) To support the pelvic organs. (2) To form protective sheath for the blood vessels and the terminal part of the ureter. (3) Infection spreads along the track, so formed, outside the pelvis Fig. 1.12: The main supporting ligaments of the uterus viewed from above  Chapter 1 Anatomy of Female Reproductive Organs 15 to the perinephric region along the ureter, to the buttock along the gluteal vessels, to the thigh along the external iliac vessels and to the groin along the round ligament. (4) Marked hypertrophy occurs during pregnancy to widen up the spaces. FEMALE URETHRA The female urethra extends from the neck of the bladder to the external urethral meatus which opens into the vestibule about 2.5 cm below the clitoris. It measures about 4 cm and has a diameter of 6 mm. Its upper half is separated from the anterior vaginal wall by loose areolar tissue and the lower half is firmly embedded in its wall. Numerous tubular glands called paraurethral glands open into the lumen through ducts. Of these, two are larger called Skene’s ducts which open either on the posterior wall just inside the external meatus or into the vestibule. These glands are the sites for harboring infection and occasional development of benign adenoma or malignant changes. While piercing the deep perineal pouch it is surrounded by sphincter urethrae membranaceae which acts as an external sphincter. STRUCTURES: Mucous membrane in the distal one-third is lined by stratified squamous epithelium but in the proximal two-third it becomes stratified transitional epithelium. Submucous coat is vascular. Muscle coat is arranged as inner longitudinal and outer circular. BLOOD SUPPLY: Arterial supply—Proximal parts are supplied by the inferior vesical branch and the distal part by a branch of internal pudendal artery. The veins drain into vesical plexus and into internal pudendal veins. LYMPHATICS: Ear the meatus, the lymphatics drain into superficial inguinal glands and the rest drain into internal and external iliac group of glands. NERVE SUPPLY: It is supplied by the pudendal nerve. DEVELOPMENT: The urethra is developed from the vesicourethral portion of the cloaca. THE URINARY BLADDER The bladder is a hollow muscular organ with considerable power of distension. Its capacity is about 450 mL (15 oz) but can retain as much as 3–4 liters of urine. When distended it is ovoid in shape. It has got— (1) an apex (2) superior surface (3) base (4) two inferolateral surfaces and (5) neck, which is continuous with the urethra. The base and the neck remain fixed even when the bladder is distended. RELATIONS: The superior surface is related with the peritoneum of the uterovesical pouch. The base is related with the supravaginal cervix and the anterior fornix. The ureters, after crossing the pelvic floor at the sides of the cervix, enter the bladder on its lateral angles. In the interior of bladder, the triangular area marked by three openings — two ureteric and one urethral, is called the trigone. The inferolateral surfaces are related with the space of Retzius. The neck rests on the superior layer of the urogenital diaphragm. STRUCTURES: From outside inwards—(1) Outer-visceral layer of the pelvic fascia. (2) Muscle layer composed of muscles running in various directions. Near the internal urethral opening the circular muscle fibers provide involuntary sphincter. (3) Mucous coat is lined by transitional epithelium with no gland. There is no submucous coat. BLOOD SUPPLY: The blood supply is through superior and inferior vesical arteries. The veins drain into vesical and vaginal plexus and thence to internal iliac veins. LYMPHATICS: Lymphatics drain into external and internal iliac lymph nodes. 16 Textbook of Obstetrics NERVE SUPPLY: The sympathetic supply is from the pelvic plexus and the parasympathetic via the pelvic plexus from the nervi erigentes (S2,3,4). The parasympathetic produces contraction of the detrusor muscles and relaxation of the internal sphincter (nerve of evacuation). Sympathetic conveys afferent painful stimuli of overdistension. DEVELOPMENT: The urinary bladder is developed from the upper part of the urogenital sinus. PELVIC URETER It extends from the crossing of the ureter over the pelvic brim up to its opening into the bladder. It measures about 13 cm in length and has a diameter of 5 mm. Ureter is retroperitoneal in course. COURSE AND RELATIONS: The ureter enters the pelvis in front of the bifurcation of the common iliac artery over the sacroiliac joint behind the root of the mesentery on the right side and the apex of the mesosigmoid on the left side. As it courses downwards in contact with the peritoneum, it lies anterior to the internal iliac artery and behind the ovary and forms the posterior boundary of ovarian fossa (Fig. 1.8). On reaching the ischial spine, it lies over the pelvic floor and as it courses forwards and medially on the base of the broad ligament, it is crossed by the uterine artery anteriorly (Fig. 1.5). Soon, it enters into the ureteric tunnel and lies close to the supravaginal part of the cervix, about 1.5 cm lateral to it. After traversing a short distance on the anterior fornix of the vagina, it courses into the wall of the bladder obliquely for about 2 cm by piercing the lateral angle before it opens into the base of the trigone. In the pelvic portion, the ureter is comparatively constricted (a) where it crosses the pelvic brim (b) where crossed by the uterine artery and (c) in the intravesical part. STRUCTURES: From outside inwards—(1) Fibers derived from the visceral layer of the pelvic fascia (2) Muscle coat consisting of three layers—outer and inner longitudinal and intermediate circular. (3) Mucous layer lined by transitional epithelium. BLOOD SUPPLY: It has got segmental supply from nearly all the visceral branches of the anterior division of the internal iliac (uterine, vaginal, vesical, middle rectal) and superior gluteal arteries. The venous drainage corresponds to the arteries. LYMPHATICS: The lymphatics from the lower part drain into the external and internal iliac lymph nodes and the upper part into the lumbar lymph nodes. NERVE SUPPLY: Sympathetic supply is from the hypogastric and pelvic plexus; parasympathetic from the sacral plexus. DEVELOPMENT: It is developed as an ureteric bud from the caudal end of the mesonephric duct. THE BREAST The breasts are large, modified sebaceous glands. The breasts are bilateral and in female constitute accessory reproductive organs as the glands are concerned with lactation following childbirth. The shape of the breast varies in women and also in different periods of life. But the size of the base of the breast is fairly constant. It usually extends from the second to sixth rib in the midclavicular line. It lies in the subcutaneous tissue over the fascia covering the pectoralis major or even beyond that to lie over the serratus anterior and external oblique. A lateral projection of the breast towards the axilla is known as axillary tail of Spence. It lies in the axillary fossa, sometimes deep to the deep fascia. The breast weighs 200–300 gm during the childbearing age. STRUCTURES (Non-lactating breasts): The areola is placed about the center of the breast and is pigmented. It is about 2.5 cm in diameter. Montgomery glands are accessory glands located around the  Chapter 1 Anatomy of Female Reproductive Organs 17 A B Figs 1.13A and B: (A) Structure of the basic unit of the mammary gland;. (B) Structure of adult female breast periphery of the areola. They can secrete milk. The nipple is a muscular projection covered by pigmented skin. It is vascular and surrounded by unstriated muscles which make it erectile. It accommodates about 15–20 lactiferous ducts and their openings. Each milk duct (lactiferous duct) dilates to form lactiferous sinus at about 5–10 mm away from its opening in the nipple. When these sinuses are pulled in to the teat during nursing, the infants tongue, facial muscles and mouth squeeze the milk from the sinuses into the infant’s oropharynx. The whole breast is embedded in the subcutaneous fat. The fat is, however, absent beneath the nipple and areola. The mature breast consists of about 20% glandular tissue and 80% fat and the rest connective tissue (Figs 1.13A and B). The breast is composed of 12–20 lobes. Each lobe has one excretory duct (lactiferous duct) that opens at the nipple. Each lobe has about 10–100 lobules. Cooper’s ligaments are the fibrous septa, that extend from the skin to the underlying pectoral fascia. These ligaments provide support to the breast. One lactiferous duct drains a lobe. The lining epithelium of the duct is cubical, becomes stratified squamous near the openings. Each alveolus is lined by columnar epithelium where milk secretion occurs. A network of branching longitudinal striated cells called myoepithelial cells surround the alveoli and the smaller ducts. There is a dense network of capillaries surrounding the alveoli. These are situated between the basement membrane and epithelial lining. Contraction of these cells squeezes the alveoli and ejects the milk into the larger duct. Behind the nipple, the main duct (lactiferous) dilates to form ampulla where the milk is stored. Breast tissue is sensitive to the cyclic changes of hormones estrogen and progesterone. Women often feel breast tenderness and fullness during the luteal phase of the cycle. During the follicular phase, there is proliferation of the ductal system whereas during the luteal phase there is dilatation of the ductal system and differentiation of the alveolar cells into secretory cells. In postmenopausal women, the