Clinical methods in obstetrics gynecology

Clinical Methods in Obstetrics and Gynecology Prelims.indd 18-07-2013 17:19:15 Prelims.indd 18-07-2013 17:19:15 Clinical Methods in Obstetrics and Gynecology Second Edition PN Nobis MBBS MD (OBG) Senior Consultant Department of Obstetrics and Gynecology International Hospital Guwahati, Assam, India Former Professor and Head Department of Obstetrics and Gynecology Silchar Medical College Silchar, Assam, India Foreword Bharati Barooah ® JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD New Delhi • London • Philadelphia • Panama Prelims.indd 18-07-2013 17:19:15 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: jaypee@jaypeebrothers.com Overseas Offices J.P Medical Ltd 83 Victoria Street, London SW1H 0HW (UK) Phone: +44-2031708910 Fax: +02-03-0086180 Email: info@jpmedpub.com Jaypee-Highlights Medical Publishers Inc City of Knowledge, Bld 237, Clayton Panama City, Panama Phone: + 507-301-0496 Fax: + 507-301-0499 Email: cservice@jphmedical.com Jaypee Medical Inc The Bourse 111 South Independence Mall East Suite 835, Philadelphia, PA 19106, USA Phone: + 267-519-9789 Email: joe.rusko@jaypeebrothers.com Jaypee Brothers Medical Publishers (P) Ltd 17/1-B Babar Road, Block-B, Shaymali Mohammadpur, Dhaka-1207 Bangladesh Mobile: +08801912003485 Email: jaypeedhaka@gmail.com Jaypee Brothers Medical Publishers (P) Ltd Shorakhute, Kathmandu Nepal Phone: +00977-9841528578 Email: jaypee.nepal@gmail.com Website: www.jaypeebrothers.com Website: www.jaypeedigital.com © 2014, Jaypee Brothers Medical Publishers All rights reserved No part of this book may be reproduced in any form or by any means without the prior permission of the publisher Inquiries for bulk sales may be solicited at: jaypee@jaypeebrothers.com This book has been published in good faith that the contents provided by the author contained herein are original, and is intended for educational purposes only While every effort is made to ensure accuracy of information, the publisher and the author specifically disclaim any damage, liability, or loss incurred, directly or indirectly, from the use or application of any of the contents of this work If not specifically stated, all figures and tables are courtesy of the author Where appropriate, the readers should consult with a specialist or contact the manufacturer of the drug or device Clinical Methods in Obstetrics and Gynecology First Edition: 1997 Second Edition: 2014 ISBN:  978-81-8448-989-7 Printed at Prelims.indd 18-07-2013 17:19:15 Foreword I have the pleasure of going through the book entitled Clinical Methods in Obstetrics and Gynecology authored by Dr PN Nobis The book is a comprehensive and updated textbook for both undergraduate and postgraduate students of obstetrics and gynecology Moreover, the author has discussed some practical problems faced by doctors in history taking and clinical examination of pregnant women in our society where ignorance, taboos and superstitions are prevalent Therefore, the book is very informative and useful guide for the doctors dealing with obstetric cases, particularly in rural areas The detection and management of high-risk pregnancies, including their early referral to well-equipped hospitals whenever necessary, are very important steps to reduce the maternal and perinatal mortality and morbidity rates This book contains a chapter on “High-Risk Pregnancy” that would be of immense help for the students as well as the practicing doctors I hope the book will receive due recognition and appreciation Bharati Barooah  MBBS  FRCOG (London) Professor Department of Obstetrics and Gynecology Guwahati Medical College Guwahati, Assam, India Prelims.indd 18-07-2013 17:19:16 Prelims.indd 18-07-2013 17:19:16 Preface to the Second Edition This is the second edition of the previous book titled “Clinical Methods in Obstetrics“ In this edition gynecological portion is added and the name of the book is changed to Clinical Methods in Obstetrics and Gynecology Few more chapters of obstetrics are added and the previous chapters are reviewed and elaborated Looking back to the anatomy and physiology classes, an attempt is made to recapitulate the basics of female genital organs Theoretical part of every chapter is reviewed before beginning the clinical examination, necessary investigations, and their interpretation Several of my past students and colleagues have rendered their valuable help in preparing the book I am really indebted to them I am very grateful to Dr Jayanti Chanda Das, Dr Karabi Patowary and Dr Kamal Kathar, for their excellent photography I am also thankful to Dr Debjani Roy Chaudhury and Dr Iheule N Khiangte, for helping me in many ways while compiling the book It is Latika and Nipak of Baruah Photostat, Bhangagarh and Mr PP Nath, who should be credited for computer typing of the whole manuscript I am specially grateful to my wife Mrs Aruna Nobis, for her constant encouragement and necessary help and to my two kids Suman and Pahi, for their help in computer works at home Finally, it is Shri Jitendar P Vij (Group Chairman), Mr Ankit Vij (Managing Director) and Mr Tarun Duneja (Director-Publishing) of M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India, who came forward to publish the book I am happy to express my gratefulness to them My work will be rewarded provided the students, for whom it is prepared, are benefited PN Nobis Prelims.indd 18-07-2013 17:19:16 Prelims.indd 18-07-2013 17:19:16 Preface to the First Edition The purpose of this book is to help the new comers who have just been introduced to the subject—obstetrics There are several excellent textbooks on obstetrics In all those books, methods of clinical examination and interpretation of the findings are scattered throughout Here an attempt is made to reproduce them together in a simple manner The need of such a book was felt while taking bedside clinics for the junior students for several years and I was prompted to prepare this The actual work was started much earlier, but it took a long time to bring the book out During this time, I am lucky to get help and encouragement from many of my friends and colleagues I am specially indebted to Dr (Ms) Bharati Barooah, FRCOG, for patiently going through the manuscript and for her valuable suggestions and encouragement She was very kind to write the foreword of the book Again, my pediatrician friend Dr CS Das, MD, Professor, Department of Pediatrics, Silchar Medical College, Assam, India, rendered valuable help in the pediatric section I am very much grateful to him I am also grateful to Dr (Mrs) Saswati Sanyal Chaudhury, MD, Assistant Professor, Department of Obstetrics and Gynecology, Guwahati Medical College, Assam, India, for her valuable suggestions and constant encouragement My thanks are due to Mr Apurba Gogoi and Mr Atanu Chaudhury, for the illustrations and to Mr B Saikia, for typing the manuscript It gives me pleasure to offer my heartiest thanks to my elder brother Sri CD Nobis and to Sri DK Saikia, for their much needed help My friend Dr NK Barua of National Printers, Guwahati, needs special mention, for taking the responsibility to bring out the book to light At last, it is my sincere hope that the book will be of some help to them for whom it is meant—my junior students PN Nobis Prelims.indd 18-07-2013 17:19:16 Prelims.indd 10 18-07-2013 17:19:16 248 Clinical Methods in Obstetrics and Gynecology that, if needed pregnancy can be terminated safely Nowadays a routine first scan is advised at 10–11 weeks of gestation to detect congenital abnormality Bleeding in Late Pregnancy One major cause of late pregnancy bleeding is low lying placenta With the help of ultrasonography placenta previa can be diagnosed almost accurately Intrauterine Fetal Death Clinical diagnosis of intrauterine fetal death is not difficult, but sometimes ultasonography is helpful Besides distortion of fetal skull, over-riding of skull bones are important signs However, absence of visible heart beat is the most reliable sign of fetal death ˆˆ CERVICAL INCOMPETENCE Cervical incompetence is an important cause of mid-trimester abortion Ultrasonographic examination of cervix is performed to evaluate the integrity of the cervix Length of the cervix, width of the cervical canal and funelling of the upper cervical canal are important parameters Normal cervical length during pregnancy is 2.5 to cm and cervix remains closed In incompetent cervix the length is less than 2.5 cm, width of the internal os is more than 15 mm in second trimester or more than mm in third trimester, funelling of cervix more than cm TVS is of more advantage than AVS to detect cervical incompetence Other conditions where ultrasonography is of help are hydramnios, and multiple pregnancy When hydramnios is diagnosed clinically ultrasonography is indicated to exclude any congenital fetal anomaly Similarity in multiple pregnancy also besides identifying multiple fetuses care is taken to exclude fetal anomaly and low lying placenta In cases with extrapelvic lump USG is used to determine the nature of the lump, namely ovarian tumor and uterine fibroid Nowadays introduction of Doppler velocimetry in ultrasound technology has facilitated the study of maternal and fetal circulatory functions With this advanced technique placental blood flow can be studied along with blood flow through umbilical artery and through the major arteries of the fetus Hence, uteroplacental blood flow and fetal cardiac activities can be studied and placental insufficiency can be diagnosed early Another method to assess fetal well-being by ultrasound is fetal biophysical profile In this procedure different fetal activities and amount of liquor amnii are assessed and fetal condition is evaluated Ultrasonography is a safe method Till date no confirmed biological effect on the mother or on the developing fetus has been reported But still its use should be judicious and a patient should be subjected to ultrasonographic examination only when genuinely indicated Chap-33.indd 248 02-07-2013 11:03:43 Radiology and Ultrasonography in Obstetrics and Gynecology 249 ˆˆ USG IN GYNECOLOGY Determination of Pelvic Mass The origin, size and consistency of a pelvic mass can be evaluated Differentiation of uterine fibromyoma, ovarian tumor, tubo-ovarian mass, endometrioma can be made In case of fibromyoma of uterus its number, exact location and size can be determined before operation is planned Endometrial Pathology Presence of endometrial hyperplasia, polyp or retained product of conception can be detected (Fig 8) TVS is more helpful than abdominal sonography Unexplained irregular bleeding or post-menopausal bleeding should be evaluated by transvaginal sonography Pelvic Malignancy A malignant ovarian tumor may be of increased size, partly solid and partly cystic The morphologic characteristics of malignant tumor are heterogeneous texture, thick septa with papillary vegetation Fig 8: Ultrasonography (Doppler) of uterus shows retained product inside Chap-33.indd 249 02-07-2013 11:03:43 250 Clinical Methods in Obstetrics and Gynecology Fig 9: Fetal biparietal diameter Fig 10: Ultrasonography of near term pregnancy showing the femur Fig 12: Ultrasonography of term pregnancy shows umbilical cord around the fetal neck Fig 11: Ultrasonography of term pregnancy showing fetal spine Fig 13: Ultrasonography of uterus shows the triple line of endometrium (arrow)    Fig 14: Chocolate cyst of ovary Chap-33.indd 250 02-07-2013 11:03:44 Radiology and Ultrasonography in Obstetrics and Gynecology 251 Blood flow pattern in a tumor can be studied by color Doppler imaging and its abnormality gives significant clue to the nature of the tumor Additional findings of malignancy are neovascularity, low impedance, etc In Infertility Ultrasonography evaluation plays an important role in initial evaluation of the patient Other indications are: yy Folliculometry–Serial measurement of ovarian follicular size and endometrial thickness are carried out to detect ovulation Ovulation is detected by appearance of internal echos, diminished size of the follicle and presence of free fluid in pouch of Douglas yy Oocyte retrieval in IVF is done under ultrasound guidance Sonohysterography Saline solution is instilled inside the uterine cavity and when studied by TVS submucous fibromyoma, endometrial polyp can be diagnosed easily Ultrasonography can be used to determine tubal patency Normal saline is pushed inside the uterine cavity passing a catheter through the cervix Ultrasound can follow the flow of fluid through the tubes Patency is confirmed by appearance of fluid in pouch of Douglas This is called sonosalpingography Another indication is to locate a missed IUCD, whether it is inside or outside the uterine cavity (Fig 16) Fig 15: Dermoid cyst of ovary   Fig 16: Intrauterine contraceptive devices seen inside the uterine cavity Chap-33.indd 251 02-07-2013 11:03:44 252 Clinical Methods in Obstetrics and Gynecology Ultrasonography is helpful to carry out some procedures, as aspiration of chocolate cyst, aspiration of tubo-ovarian abscess and to take biopsy In IVF clinic ultrasonographic assisted ovum retrieval is done ˆˆ COMPUTED TOMOGRAPHY CT scan provides multiple cross-sectional images of the part of the body at short distance In gynecology CT scan helps to evaluate pelvic mass particularly in staging of malignant conditions Cervical Carcinoma CT scan is indicated in poorly differentiated, bulky tumor mass It can detect metastatic lymph nodes in pelvis and extension of the lesion to the pelvic wall It can diagnose hydroureter, hydronephrosis or bowel involvement by the lesion Thereby can eliminate the need of intravenous urography or barium enema CT scan is not used in obstetrics, due to irradiation ˆˆ MAGNETIC RESONANCE IMAGING MRI also provides cross-sectional images of the body MRI is indicated only when USG diagnosis is inadequate or for staging of carcinoma It gives excellent soft tissue detail of pelvic organs No doubt it is superior to USG or CT scan but it is more expensive MRI can clearly differentiate congenital anomalies of uterus Fibromyoma of uterus are better diagnosed with details It is indicated in cases of endometrial carcinoma where it can clearly demonstrate myometrial involvement of the disease In carcinoma cervix it is used to know accurately, the parametrial invasion by the carcinoma Metastasis to urinary bladder and rectum can be demonstrated MRI is superior to CT in detecting lymph gland metastasis in any pelvic malignancy It can also be used to evaluate origin and nature of any pelvic mass like tubo-ovarian mass or abscess, endometrioma and ovarian tumor ˆˆ IN OBSTETRICS The role of MRI is not well-established in the field of obstetrics No irradiation is used in MRI but still its possible adverse effects on unborn fetus is not fully evaluated In obstetrics USG is the better option though MRI can provide clear information about fetal anomaly, intrauterine fetal death, site of placentation and placental pathology USG is easier and cheaper procedure and undoubtedly the method of choice Chap-33.indd 252 02-07-2013 11:03:44 Index Page numbers followed by f refer to figure A Abdominal auscultation 69 circumference 125 enlargement 77 examination 58, 59, 68, 140, 142, 147, 206, 234 palpation 68 percussion 69 Abnormal position 137 presentation 137 Abnormality, duration of 176 Accidental hemorrhage 115f Acute abdomen during pregnancy 226 causes of 226 salpingo-oophoritis 231 vulvitis 188f Adenomyosis 174 of uterus 207f Age menarche 47 Alcohol 160 Alpha fetoprotein 124 Amenorrhea 76, 180 causes of 180 examination of 182 Amniocentesis 127 risk of 128 Amnion 33 Amniotic fluid 35 bilirubin 127 volume 126 Android 36 pelvis 36f Anemia 168 Antepartum fetal monitoring 120 Anterior fontanelle 92f Anthropoid 37 pelvis 36f Index.indd 253 Apgar score 132, 133 Arcuate uterus 40f Arterial supply of pelvis 9f Atrophy 204 Atypical vascular pattern 219 Autonomic nerves 11 Azoospermia 194 B Baby resuscitation machine 135f Back pain 47 Bacterial vaginosis 187 Barrel shaped cervix 224f Bartholin cyst 172f Basal body temperature 191 chart 191f Baseline bradycardia 130 fetal heart rate 129 tachycardia 130 Basic care of newborn birth 132 Battledore placenta 33f fetal surface 114f maternal surface 114f Beat to beat variation 130 Bethesda classification 218 Bicornuate uterus with rudimentar horn 40f Big submucus myoma 203f Bilateral patent tubes 192f Bilobed placenta 115f Bimanual examination 118, 207 Biochemical test 123 Biopsy 220 types of 239 Biparietal diameter 125 Biparietal diameter of fetal head 95f Birth canal during labor 96f Bishop score 67 Bladder function 115 18-07-2013 10:03:27 254 Clinical Methods in Obstetrics and Gynecology Blastocyst 21f Bleeding in early pregnancy 245 late pregnancy 248 phase, duration of 48 Blood examination of 235 pressure 55, 233 supply of pelvis of uterus 5f Body of uterus 10 Braxton Hicks contraction 60 present 82 Breast 7, 115, 136 examination of 58, 74 symptoms 76 Breech presentation 145 sacroposterior 146f types of 145 with extended leg 147f with flexed leg 147f Brow presentation 144, 144f C Calculation of expected date of delivery 48 Canalization of Müllerian cords, failure of 41 Candida albicans 188 Caput succedaneum 94 Carcinoma cervix 217 staging of 224f confined to the cervix 224f extends to upper vagina 224f vulva 215 on examination 215 staging 216 symptoms 215 Cardiac output 58 Cardiotocography 123 Cardiovascular system 57 Cells exfoliate 217 Cellular elements 194 Central cervical tumor 203 Cephalopelvic disproportion 108 Cephalopelvic disproportion, assessment of 109f Index.indd 254 Cervical 202 biopsy 239 canal 192 carcinoma 252 dilatation curve 87 erosion 221 factor 192 glands 187 incompetence 248 polyp 72f smear for Pap staining 237f with Ayer’s specula 238 Cervicograhy 219 Cervix 10, 90, 91, 96f after application of acetic acid 219 after delivery 116f developmental anomaly of 40 dilatation of 85 dilates 93 in early labor 91f in pregnancy 85f inspection of 71 short 91f Changes during pregnancy 226 Changes in pelvis caused by fibromyoma of uterus 204 Chocolate cyst of ovary 250f Chorion 31 CIN, degree of 218 Circumvalet placenta 32f Cleavage two-cell stage to morula 20f Clinical signs of pregnancy 78 Clinical staging based on FIGO 216 Clitoris Collagen fibers 34 Color of liquor amnii 94 Colostrum 76 Colposcopy 219, 238 Common vaginal speculum 72f Complete prolapse 197f with cystocele 196f Compound presentation 151 Concealed menstruation 180 (See Cryptomenorrhea) Conditions mimic genital prolapse 201 Cone biopsy 239 complications of 240 18-07-2013 10:03:27 Index 255 Congenital anomalies detection of 247 of vulva 39 Congenital elongation of cervix 201 malformation of female genital tract 39 Contraception 167 Contraceptive, history of 51 Contraction stress test 127 Cord presentation and cord prolapse 151 Corneal block 192f Coronal suture 92f Corpus luteum 16 Crowning of head 88 Cryptomenorrhea 180 menstrual blood collected in vagina 181f with bulging hymen 181f Cusco’s bivalve speculum 72 speculum 53, 72 Cystic degeneration 203 nature 81 Cystocele 195, 199 Cytological examination 218 D Deceleration pattern 129 Decidua 22 basalis 23 capsularis 23, 76 vera 23, 76 Degenerated submucus fibromyoma of uterus 205f Delivery, mode of 168 Dermatological conditions 213 Dermoid cyst of ovary 251f with hair 170 Developing embryo implented inside uterine wall 22f Diabetes mellitus 50 Diagnostic indications 240, 241 procedures in gynecology 240 Diagonal conjugate 107f Dialatation of cervix, assessment of 92f Different breech presentation 147f Disturbed ectopic pregnancy 228 Index.indd 255 Dorsal position 70 Double cervix 40f uterus 40f vagina 40f Drugs 160, 101 During labor 149 During pregnancy 149 Dye test 211 Dysmenorrhea 206, 230 Dysplasia, degree of 218 E Ear 136 Echogenic periphery 79 Ectopic pregnancy 246 corneal, sites of 228 fimbrial, sites of 228 isthemic, sites of 228 ovarian, sites of 228 Edema 56 Effaced cervix with partial dialatation 91f Electronic fetal heart monitoring, danger of 131 fetal monitoring 126 Embryo and cardiac activity 80 Embryological development Endocrinology of menstruation 17 Endometrial biopsy 192 carcinoma 205 pathology 249 Endometriosis 175, 205, 232 Endometrium in proliferative phase with tubular glands 17f secretory phase with dilated glands 18f Enterocele 195 Enzymes 124 Epimenorrhea 177 (See Polymenorrhea) Estimation of gestational age 247 Estrogens 124 Examination, method of 70 Excessive vaginal discharge 187 External ballotment 61 electronic monitoring 129 reproductive organs Extremeties protrude 80 18-07-2013 10:03:27 256 Clinical Methods in Obstetrics and Gynecology F Face after delivery, appearance of 144f presentation 142, 142f with submentovertical diameter 143f Factors affecting intrauterine fetal activity 119 Fallopian tubes 7, 205 False labor 85 Fatty degeneration 203 Female fetus 39 genital organs pelvis 106f types of 36f Fern pattern of cervical mucus 193f test 193 Fetal biophysical profile 125 biparietal diameter 250f blood sampling 130 breathing movement 126 circulation 26, 28f changes after birth 26 condition, assessment of 97 head, attitude of 65f heart auscultation of 65 rate pattern 129 recording 99 sound present 82 variability 122f membranes 31, 31f movement in intrauterine life 119 ovoid 137f parts, palpation of 61, 78 scalp blood sampling 131 skull in vertex presentation, measurement of 88f of biparietal diameter 80f position of anterior fontanelle 95f position of bi-temporal diameter 95f position of posterior fontanelle 95f term 92f surface of normal placenta 111f tone 126 well being, assessment of 119 Index.indd 256 Fetus 24 hydrocephalus 164f inside uterus in periods of gestation 27f size of 90 stages of development 27f Fibroid polyp 221 Fibromyoma of uterus 202 First stage of labor 86 Foam stability test 127 Follicle, growth of 15 Frontal suture 92f Full bladder 81, 173 Full term fetus 27f Fully effaced cervix 91f Fundal grip 62, 63f height 61 (See Height of fundus) Fundus height of 61, 61f, 113 Fusion of Müllerian duct, defect in 41 G Gait 54 Galactorrhea 81 Gallbladder disease 227 Gartner’s duct cyst 40 Gastrointestinal system 58 relation with 52 Gastrointestinal tract 232 General appearance 54 General health 116 Genetic causes 160 Genital prolapse 195, 196f, 198 types of 197f Genitalia 136 Germinal layers with formation of villi 29f Gestation age, large of 135 Gestational age 135 after birth, assessment of 135 appropriate for 135 assessment of 245 Gestational sac of early pregnancy with yolk sac  244f Girth of abdomen 60 Graafian follicle 16f Gradual enlargement of uterus 78, 82 Gross body movement 126 vulval edema 66f 18-07-2013 10:03:27 Index 257 Gum 56 Gynecoid pelvis 36f Gynecological condition 167, 230 examination 68 Gynecology 51 H Hands splay 65 Head fully extended face presentation 65f flexed vertex presentation 65f Head descent of 100 grossly deflexed brow presentation 65f Heart disease 49 High risk pregnancy, identification of 166 Hot flush 184 HPV testing 219 Human breast, structure of 8f chorionic gonadotropin 124 papilloma virus DNA 215 placental lactogen 124 Husband’s semen, analysis of 193 Hyaline degeneration 203 Hypertension 50, 169 Hysterosalpingography 192, 242 of bicornuate uterus 242f of septate uterus 242f Hysteroscopy 208, 241 I Identification of gestational sac 79 Iliac spine 65 Iliococcygeus 13 Imperforated hymen 39 Implantation 21 Infertility 251 Inguinal lymph nodes 11f Internal iliac artery monitoring of fetal heart 129 OS dialated 91f pudendal artery Intrapartum monitoring 128 methods of 128 Index.indd 257 Intrauterine contraceptive devices uterine cavity 251f death 164f fetal death 162, 164f, 248 growth restriction 159, 247 Intravenous fluids 101 Invasive carcinoma cervix 220 staging of 222 Irregular bleeding 206 Ischiococcygeus 13 J Jaundice 56 K Kidney diseases 50 Korotkoff sound 55 L Labia minora Labor diagnosis of 96 duration of 89, 99 examination in 83 graph, components of 99 Lamboidal suture 92f Lanugo 136 Laparoscopy 192, 208, 234, 240 Large numbers of leukocytes 3f Late deceleration 122f, 129 Late in labor 150 Lateral cervical fibromyoma 203 grip 63, 63f Leukoplakia 219 Levator ani 12 muscle 12f, 13f Lichen sclerosus 213 Ligaments of uterus 4, 5f Lipoma of right labia majora 172f Liquor 99 ammii 85, 86 functions of 35 Lithotomy position 70 Lochia 113 examination of 114 Lower abdominal swelling 80 18-07-2013 10:03:27 258 Clinical Methods in Obstetrics and Gynecology Lump abdomen, examination of 170 Lung maturity, assessment of 127 Lying in period 111 Lymph glands 215 Lymphatic drainage 10 M Malaise 77 (See Tiredness) Malignant change 204 Mammary murmur 57 Marital status 45, 167 Maternal causes 159 condition 101 assessment of 97 disease 159 nutrition 160 surface of normal placenta 110f Mature baby after birth 133f Matured placenta, structure of 32f Mayer-Rokitansky-Küster-Hauser syndrome 40 Membranes absence of 94 examination of 112f rupture of 88 Meningocele 164f Menometrorrhagia 177 Menopausal problems 184 Menorrhagia 176, 206 Menstrual abnormality 176, 206 blood loss 15 cycle 15, 19f history 47, 167, 232 period 15 Menstruation 15 relation with 52 Mentoposterior position, right 142f Metrorrhagia 177, 206 Micturition, frequency of 46, 77, 209 Mid stream urine collection 236 Midline longitudinal septum 40 Midluteal serum progesterone 192 Mixed dystrophy 214 Monilia 237 vaginitis 188 Montgomery’s tubercle 82 Mosaic 219 Index.indd 258 Moulding 96 of fetal head in brow presentation 145f face presentation 143f occipitoanterior 141f occipitoposterior position 141f Mucus polyp 221 Müllerian duct 40 Multiparous 85f woman cervix 91f women 77 Multiple fibromyoma of uterus 204f pregnancy 153, 160 Munro Kerr’s method 109f Muscle cramp 47 N Nausea 46, 77 Neck veins 56 Necrosis 204 Necrozoospermia 194 Nerve supply 10 Newborn immediately after birth 132 Nipple, examination of 58 Non-stress test 126 Normal size uterus 81 Nulliparous 85f Nutrition 54 O Observation in labor 83, 97 Obstetric 252 attitude 59 conjugate 107f examination 59, 67, 89 position 59 presentation 59 Obstetrical causes 227 Obstructed labor 103 Occipitoposterior position 138 of vertex presentation 139f Occiput, diagnosis of position of 140f Oligomenorrhea 178 Oligozoospermia 194 Oncogenic irritants 218 Onset of labor 83 Ovarian artery 18-07-2013 10:03:27 Index 259 cycle 15 cyst, rupture of 231 neoplasm, torsion of 231 tumor 81, 173 complications of 230 tumor, torsion of 229 Ovaries 6f, 7, 205 Overflow incontinence 212 Ovulation 15, 22f detection of 191 growth of 15 Ovulatory factor 191 Oxytocin stimulation 101 P Pain 46, 48, 51, 84 abdomen 51 Pap smear 238 Parabasal layer 217 Partially dialated cervix 91f Partogram 99, 101f Past gynecological history 50 Past medical history 167 Past obstetric history 168, 233 Patient with acute abdomen, examination of 226 prolong labor, examination of 102 Patient, examination of 178, 199 Pattern of abnormality 176 Pawlik’s grip 63, 63f, 64f Pelvic assessment 105, 108f axis 107f examination 117, 191 floor 12, 12f grip 63f, 64 inflammatory disease with hydrosalpinx 231f inlet, diameters of 37f lymph nodes 216 malignancy 249 mass 201 determination of 249 organ 77 wall lower-third of vagina 225 Pelvis, types of 36 Perineal body 14 muscles 13 Index.indd 259 Perineum distending vulva 88 examination of 116 Placenta abnormality of 32 after expulsion, examination of 112f development of 29 examination of 110, 111, 157 formation of 31f of binovular twin with fused margin fetal surface 158f maternal surface 158f succenturiata 112f with decidua, relation of 31f with fetal membranes, relation of 30f Placental cause 160 Platypeloid pelvis 36f Plenty of pus cells 188 Polymenorrhea 177 Position of fetus 62 occiput 94f diagnosis of 141f Posterior cervical fibromyoma 203 funtanelle 92f vaginal wall 199, 200 Postmenopausal bleeding 185 Postnatal examination 116 Predisposing factors 154 Pregnancy 173 complications of 162 culminates in labor 83 diagnosis of 76, 77 indications in first trimester of 244 symptoms of 76, 81 Preinvasive carcinoma of cervix 217 Premature baby 133f Primary amenorrhea, causes of 180 Primigravida 77 Progress of labor, assessment of 98 Proliferative phase large cells with pyknotic nuclei 3f Prolonged labor with signs of obstruction 103 without signs of obstruction 103 Pruritus vulvae 187, 213 Pseudocyesis 81 Pubococcygeus 12 18-07-2013 10:03:27 260 Clinical Methods in Obstetrics and Gynecology Pulmonary tuberculosis 50 Pulse 55, 233 and temperature 113 Punch biopsy 239 Punctation 219 Q Quickening 49 R Radiological signs of fetal death 164 Radiology in obstetrics and gynecology 242 Rectal examination 74 Rectocele 195 prolapse 197f Rectovaginal examination in enterocele 200f Red degeneration 204 Religion 45 Renal causes 227 Respiration, difficulty in 47 Respiratory system 58 Retroverted gravid uterus 81 Rheumatic fever 49 Right occipito anterior 94f lateral 94f posterior 94f Ripe cervix 67, 85 Ruptured uterus 103 S Sagittal suture 92f Scar of anterior abdominal wall 68f Second degree genital prolapse 197f of labor 87 prolapse 196f uterine prolapse 196f Secondary amenorrhea 181 areola 82 Secretory phase 3f Semen analysis 193 Semiprone position 70 Sensation of fetal movement 77 Septate uterus 42 vagina 40f Index.indd 260 Sexually transmitted disease 188 Shake test 127 (See Foam stability test) Shoulder presentation 148 Signs of pregnancy 77, 81 Sim’s bivalve posterior vaginal speculum 72f double bladed speculum 71 position 70, 70f speculum 71 Sites of ectopic pregnancy 228 Skin 136 Skull firmness 136 Small for date 135 (See Gestational age) Smoking 159 Social status 233 Socioeconomic conditions 167 Sole creases 136 Sonohysterography 251 Sonolucent sac 79 Speculum examination 71 Sperm count 194 morphology 194 motility 194 Spermatozoa 19 Spinnbarkeit test 193 Spread of growth to adjacent organs 225 Spread to distant organs 225 Spurious pregnancy 81 (See Pseudocyesis) Sria gravidarum 60f Stages of labor 85 Station of fetal head 95f Stress urinary incontinence 211 Submucus 202 Sub-pubic angle 38f narrow 38f wide 38f Subserous 202 Succenturiate placenta 33f Superficial layer 217 perineal muscle 13f Suprapubic region in midline 81 Surgical history 50 Swelling of leg 47 Sympathetic 11 Symphysis fundal height measurement 121 measurement of 60 Syphilitic ulcer 221 Systemic examination 57 18-07-2013 10:03:27 Index 261 T Teeth 56 Teratozoospermia 194 Term fetus inside uterus 83f Third stage of labor 88 Three cardinal signs 84 of labor 84 Tiredness 77 Tortuous uterine arteries 65 Transverse lie 148 (See Shoulder presentation) Transverse lie 149f with hand prolapse 150f, 151f Trauma 131 Treatment received outside, history of 89 Triangular ligament 13 Trichomonas vaginalis 188, 237 Triple test 123 True incontinence 210 Tubal patency test 192 Tubercular ulceration 221 Tubo-ovarian mass 174 Twenty-four hours urine specimen 236 Type of urine specimen 236 U Ultrasonography Doppler of uterus 249f fibromyoma 207f in obstetrics and gynecology 242, 243 indications of 244 of anembryonic sac 245f of cord round neck 34 of disturbed ectopic pregnancy 246f of early gestational sac with yolk sac 80f of early pregnancy 244f fetal limbs 80f of hydatidiform mole 246f of near term pregnancy showing the femur 250 of pregnancy 80f of term pregnancy fetal spine 250 umbilical cord around fetal neck 250f of twin pregnancy 156f inter-twin membrane 157f of uterus triple line of endometrium 250f Index.indd 261 Umbilical cord 34, 34f false knot 34f from left 34f normal 34f true knot 34f Umbilical vessels from trauma 34 Unruptured tubal ectopic pregnancy 229f pregnancy 229f Ureter 205 Urethra, descent of 195 Urethral meatus Urge incontinence 212 Urinary incontinence 209 system abnormalities of 209 relation with 52 Urine 101 collected using a catheter 236 examination of 236 specimen collection of 236 concentrated urine 236 Urogenital fistula, types of 210f Urologic causes 232 USG in gynecology 249 Uterine abnormalities 40f artery contraction 98, 101 factor 193 fibromyoma 81, 174, 230 muscle fibers during labor 86f prolapse 195 septa 40f sign 78 systole 84 Uterus 7, 96f, 204 after delivery 117f bicornis bicollis 41 unicollis 41 developmental anomaly of 40, 41 didelphys 40f, 41 different parts of 5f inside vagina 200 labor, rupture of 104 of pregnancy 61f palpable per abdomen 81 pregnancy, rupture of 104 18-07-2013 10:03:28 262 Clinical Methods in Obstetrics and Gynecology size of 169 unicornis 41 with advance of pregnancy 84f with tubes and ovaries 2f with urinary bladder and rectum, relation of 4f V Vagina 2, 10, 39, 96f, 200 after hysterectomy 200 Vaginal artery bleeding 47 discharge 47 discharge causes of 188 collection of 237 examination 66, 69, 90, 140, 143, 148, 150, 174, 175, 220 during labor 98 opening smear 3f wall 188 Index.indd 262 Variable deceleration 130 Varicose veins 57 Varities of congenital anomaly 39 Vascular changes 204 Veins 10 Venereal disease 50 Ventral folding 80 Vestibule Villus formation, stages of 30f Vomiting 46, 77 Vulva 10 examination of 116 Vulval swelling 172 W Wedge biopsy 239 Wharton’s jelly 34 White discharge 46 Wide fontanelles 92f Y Yolk sac 79 18-07-2013 10:03:28 ... 14:53:24 10 Clinical Methods in Obstetrics and Gynecology Veins The veins accompany the arteries having the same name and drain into the internal iliac vein Right ovarian vein drains into the inferior... laterally to enter the inguinal canal, passing through the canal terminate in the labia majus Chap-01.indd 01-07-2013 14:53:23 Clinical Methods in Obstetrics and Gynecology Cardinal ligaments or Mackenrodt’s... titled ? ?Clinical Methods in Obstetrics? ?? In this edition gynecological portion is added and the name of the book is changed to Clinical Methods in Obstetrics and Gynecology Few more chapters of obstetrics