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OXFORD HANDBOOK OF

Obstetrics and Gynaecology

FOURTH EDITION

edited by

Sally Collins

Consultant Obstetrician and Subspecialist in Maternal and Fetal Medicine, John Radcliffe Hospital, Oxford, and Professor of Obstetrics, Nuffield Department of Women’s and Reproductive Health, University of Oxford, Oxford, UK

Sabaratnam Arulkumaran

Professor of Obstetrics and Gynaecology, University of Nicosia Medical School, Cyprus, Professor Emeritus, St George’s, University of London, and Visiting Professor, Imperial College London, London, UK

Kevin Hayes

Consultant Obstetrician and Gynaecologist, St George’s University Hospital NHS Foundation Trust, London, UK

Kirana Arambage

Consultant Gynaecologist, John Radcliffe Hospital, Oxford, and Honorary Senior Clinical Lecturer, Nuffield Department of Women’s and Reproductive Health, University of Oxford, Oxford, UK

Lawrence Impey

Consultant Obstetrician and Subspecialist in Maternal and Fetal Medicine, John Radcliffe Hospital, Oxford, UK

Great Clarendon Street, Oxford, OX2 6DP, United Kingdom

Oxford University Press is a department of the University of Oxford. It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide. Oxford is a registered trade mark of Oxford University Press in the UK and in certain other countries

The moral rights of the authors have been asserted

First Edition published 2005

Second Edition published 2008

Third Edition published 2013

Fourth Edition published 2023

Impression: 

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, by licence or under terms agreed with the appropriate reprographics rights organization. Enquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above

You must not circulate this work in any other form and you must impose this same condition on any acquirer

Published in the United States of America by Oxford University Press 98 Madison Avenue, New York, NY 006, United States of America

British Library Cataloguing in Publication Data

Data available

Library of Congress Control Number: 2022941170

ISBN 978–0–9–883867–8

DOI: 0.093/med/978098838678.00.000

Printed and bound in China by C&C Offset Printing Co., Ltd.

Oxford University Press makes no representation, express or implied, that the drug dosages in this book are correct. Readers must therefore always check the product information and clinical procedures with the most up-to-date published product information and data sheets provided by the manufacturers and the most recent codes of conduct and safety regulations. The authors and the publishers do not accept responsibility or legal liability for any errors in the text or for the misuse or misapplication of material in this work. Except where otherwise stated, drug dosages and recommendations are for the non-pregnant adult who is not breast-feeding

Links to third party websites are provided by Oxford in good faith and for information only. Oxford disclaims any responsibility for the materials contained in any third party website referenced in this work.

Preface

Since the previous edition of the Oxford Handbook of Obstetrics and Gynaecology there has been significant growth within the specialty, with new reports and guidelines that have changed the approaches involved in delivering the best-quality care for patients. In writing and developing this new edition, we have taken the latest evidence-based practice as well as our own clinical experience to help those of you who are embarking on the challenging yet rewarding field of obstetrics and gynaecology.

We are grateful to our past and present contributors, who have given both their time and expertise in writing and updating this Handbook, as well as to our readers. We hope that the information, which we have tried to present in a digestible format, will prove useful to you on the wards as well as at your desk. Where possible, we have tried to align our chapters with the Royal College of Obstetricians and Gynaecologists curriculum, but we have also included clinical tips gleaned from our practical experience. Please do let us know any suggestions or criticism related to the content of the book, and we will make every effort to improve the delivery of the content even more in the next edition.

Sally Collins Sabaratnam Arulkumaran

Kevin Hayes Kirana Arambage

Lawrence Impey April 2022

Acknowledgements

We would like to thank all our second and third edition authors on whose sterling work this latest edition is built. We would also like to thank the doctors of all grades who anonymously reviewed some of the text, providing valuable feedback and further fine-tuning of the finished manuscript. To conform to the Oxford Handbook style and to avoid overlap and repetition, some contributions have been considerably edited and we thank all our authors for their understanding. We are most grateful to Prof. Basky Thilaganathan for providing many of the ultrasound images and Ms Penny Trotter for the colposcopy pictures. We cannot fail to mention the marvellous team at Oxford University Press including Elizabeth Reeve, Helen Liepman, and Caroline Smith, but especially Sylvia Warren without whose incredible patience, kindness, and expert guidance this fourth edition would not have happened. Last, but definitely not least, we would like to thank our partners and families who continue to remain so patient and supportive throughout this project, especially Berni O’Connor, ‘for doing all the real work on the home front’ and David, Lexi, and Bea Reynard ‘for all their love and support throughout M’s mad projects’.

Symbols and abbreviations

H warning

2 important

3 differential diagnosis controversial

E cross-reference

M website z video

° primary

2° secondary i increased

d decreased

l leading to ± with or without approximately

+ve positive

−ve negative

5-FU 5-fluorouracil

ABG arterial blood gases

ACE angiotensin converting enzyme

ACEI angiotensin converting enzyme inhibitor

ACTH adrenocorticotropic hormone

ADH antidiuretic hormone

AF atrial fibrillation

AFI amniotic fluid index

AFLP acute fatty liver of pregnancy

AFP alpha-fetoprotein

AIS androgen insensitivity syndrome

ALP alkaline phosphatase

ALT alanine transaminase

AMH anti-Müllerian hormone

ANA antinuclear antibodies

APH antepartum haemorrhage

APS antiphospholipid syndrome

AREDF absent/reversed enddiastolic flow

ARM artificial rupture of membranes

ASD atrial septal defect

AST aspartate aminotransferase

AVM arteriovenous malformation

BASHH British Association for Sexual Health and HIV

BCG bacillus Calmette–Guérin

bd twice daily

BEP bleomycin, etoposide, and cisplatin

βhCG beta-human chorionic gonadotropin

BMD bone mineral density

BMI body mass index

BOT borderline ovarian tumour

BP blood pressure

BPD biparietal diameter

BRCA breast cancer gene

BSO bilateral salpingo-oophorectomy

BV bacterial vaginosis

CA cancer antigen

CAH congenital adrenal hyperplasia

CAIS complete androgen insensitivity syndrome

CAP chest/abdomen/pelvis

cART combination antiretroviral therapy

CBAVD congenital bilateral absence of the vas deferens

CD Caesarean delivery

CEA carcinoembryonic antigen

CF cystic fibrosis

CGIN cervical glandular intraepithelial neoplasia

CI confidence interval

CIN cervical intraepithelial neoplasia

CMV cytomegalovirus

CNS central nervous system

CNST Clinical Negligence Scheme for Trusts

CO2 carbon dioxide

COCP combined oral contraceptive pill

COVID-9 coronavirus disease 209

CP cerebral palsy

CPAP continuous positive airway pressure

CPP chronic pelvic pain

CPR cerebroplacental ratio or cardiopulmonary resuscitation

CRL crown–rump length

CRP C-reactive protein

CS Caesarean section

CSF cerebrospinal fluid

CT computed tomography

CTG cardiotocography

CTPA computed tomography pulmonary angiogram

CVS chorionic villus sampling

CXR chest X-ray

DC dichorionic

DCDA dichorionic and diamniotic

DES diethylstilbestrol

DHEAS dehydroepiandrosterone sulphate

DIC disseminated intravascular coagulation

DSD disorder of sex development

DUB dysfunctional uterine bleeding

dVIN differentiated vulval intraepithelial neoplasia

EBL estimated blood loss

EBRT external beam radiotherapy

ECG electrocardiography/ electrocardiogram

ECV external cephalic version

EDD expected date of delivery

EFW estimated fetal weight

EP ectopic pregnancy

EPAU early pregnancy assessment unit

ESR erythrocyte sedimentation rate

ET endometrial thickness

ETT endotracheal tube

EUA examination under anaesthetic

FBC full blood count

FBS fetal blood sampling

FDA Food and Drug Administration

FF fetal fraction

FFP fresh frozen plasma

FGM female genital mutilation

FGR fetal growth restriction

FH fetal heart

FHR fetal heart rate

FIGO International Federation of Gynaecology and Obstetrics

FL femur length

FM fetal movements

FPR false-positive rate

FSD female sexual dysfunction

FSH follicle-stimulating hormone

FVS fetal varicella syndrome

GA general anaesthesia

GABA gamma-aminobutyric acid

GAD generalized anxiety disorder

GAS group A Streptococcus

GBS group B Streptococcus

GDM gestational diabetes mellitus

GFR glomerular filtration rate

GMC General Medical Council

GnRH gonadotropin-releasing hormone

GP general practitioner

GTD gestational trophoblastic disease

GTN gestational trophoblastic neoplasia

GTT glucose tolerance test

GUM genitourinary medicine

Hb haemoglobin

HbA adult haemoglobin

HbAc glycated haemoglobin

HBeAg hepatitis B e antigen

HbF fetal haemoglobin

HBsAg hepatitis B surface antigen

HBV hepatitis B virus

HC head circumference

hCG human chorionic gonadotropin

HELLP haemolysis, elevated liver enzymes, and low platelets

HFEA Human Fertilization and Embryology Authority

HG high-grade serous ovarian carcinoma

HIV human immunodeficiency virus

HLA human leucocyte antigen

HMB heavy menstrual bleeding

HPO hypothalamic–pituitary–ovarian

HPV human papillomavirus

hrHPV high-risk human papillomavirus

HRT hormone replacement therapy

HSG hysterosalpingography

HSV herpes simplex virus

HVS high vaginal swab

HyCoSy hysterosalpingo contrast sonography

IBD inflammatory bowel disease

ICD- International Classification of Diseases, th Revision

ICD-MM International Classification of Diseases for Maternal Mortality

ICG indocyanine green

ICP intrahepatic cholestasis of pregnancy

ICSI intracytoplasmic sperm injection

IDS interval debulking surgery

Ig immunoglobulin

IHC immunohistochemistry

IM intramuscular

IMB intermenstrual bleeding

IOL induction of labour

IUCD intrauterine contraceptive device

IUD intrauterine death

IUI intrauterine insemination

IUP intrauterine pregnancy

IUS intrauterine system

IV intravenous

IVF in vitro fertilization

IVU intravenous urography

JVP jugular venous pressure

LARC long-acting reversible contraceptive

LDH lactate dehydrogenase

LFT liver function test

LGSOC low-grade serous ovarian carcinoma

LH luteinizing hormone

LLETZ large loop excision of transformation zone

LMP last menstrual period

LMWH low-molecular-weight heparin

LN lymph node

LNG levonorgestrel

LVS low vaginal swab

MBRRACE-UK Mothers and Babies: Reducing Risk through Audits and Confidential Enquiry across the UK

MC monochorionic

MCA middle cerebral artery

MCDA monochorionic and diamniotic

MCHC mean corpuscular haemoglobin concentration

MCMA monochorionic and monoamniotic

MCV mean corpuscular volume

MDT multidisciplinary team

MEA microwave endometrial ablation

Mg magnesium

MMR measles, mumps, and rubella or mismatch repair

MPA medroxyprogesterone acetate

MRI magnetic resonance imaging

MRKH Mayer–Rokitansky–Küster–Hauser

MSAF meconium-stained amniotic fluid

MSU midstream sample of urine

MTCT mother-to-child transmission

NAAT nucleic acid amplification test

NEC necrotizing enterocolitis

NHSCSP NHS Cervical Screening Programme

NHSLA National Health Service Litigation Authority

NICE National Institute for Health and Care Excellence

NIPT non-invasive prenatal testing

NPV negative predictive value

NSAID non-steroidal antiinflammatory drug

NT nuchal translucency

NTD neural tube defect

OA occipito-anterior

OAB overactive bladder

od once daily

OGTT oral glucose tolerance test

OHSS ovarian hyperstimulation syndrome

OL occipito-lateral

OP occipito-posterior

PAIS partial androgen insensitivity syndrome

PAPP-A pregnancy-associated plasma protein-A

PAS placenta accreta spectrum

PCB postcoital bleeding

PCOS polycystic ovary syndrome

PCR protein:creatinine ratio or polymerase chain reaction

PE pulmonary embolism

PEFR peak expiratory flow rate

PEP postexposure prophylaxis

PET pre-eclampsia toxaemia

PG prostaglandin

PGE prostaglandin E

PGE2 prostaglandin E2

PID pelvic inflammatory disease

PlGF placental growth factor

PMB postmenopausal bleeding

PMRT Perinatal Mortality

Review Tool

PMS premenstrual syndrome

PO per os (by mouth)

POF premature ovarian failure

POMB/ACE cisplatin, vincristine, methotrexate, bleomycin, dactinomycin, cyclophosphamide, and etoposide

POP progestogen-only pill

PPH postpartum haemorrhage

PPROM preterm prelabour rupture of membranes

PPV positive predictive value

PROM prelabour rupture of membranes

PSV peak systolic velocity

PUL pregnancy of unknown location

PV per vaginam

Q ventilation

qds four times daily

RCOG Royal College of Obstetricians and Gynaecologists

RCT randomized controlled trial

Rh rhesus

RID relative infant dose

RMI risk of malignancy index

ROM rupture of membranes

RR rate ratio or relative risk

RRBSO risk-reducing bilateral salpingo-oophorectomy

RUQ right upper quadrant

SARC sexual assault referral centre

SARS severe acute respiratory syndrome

SC subcutaneous

SFH symphysis fundal height

sFlt- soluble FM-like tyrosine kinase 

SGA small for gestational age

SHBG sex hormone-binding globulin

SLE systemic lupus erythematosus

SLN sentinel lymph node

SLNB sentinel lymph node biopsy

SMM surgical management of miscarriage

SNRI serotonin and norepinephrine reuptake inhibitor

SROM spontaneous rupture of membranes

SSRI selective serotonin reuptake inhibitor

STI sexually transmitted infection

STIC serous tubal intraepithelial carcinoma

T3 triiodothyronine

T4 thyroxine

TAS transabdominal scan

TB tuberculosis

Tc technetium

tds three times daily

TENS transcutaneous electrical nerve stimulation

TFT thyroid function test

TNF tumour necrosis factor

TOP termination of pregnancy

TSH thyroid-stimulating hormone

TTP thrombotic thrombocytopenic purpura

TTTS twin-to-twin transfusion syndrome

TV transvaginal

TVS transvaginal scan

TVT tension-free vaginal tape

U&E urea and electrolytes

UKFOCSS UK Familial Ovarian Cancer Screening Study

UN United Nations

UPSI unprotected sexual intercourse

USI urodynamic stress incontinence

USS ultrasound scan

UTI urinary tract infection

uVIN usual-type vulval intraepithelial neoplasia

V/Q ventilation/perfusion

VBAC vaginal birth after Caesarean

VDRL Venereal Disease Research Laboratory test

VE vaginal examination

VEGF vascular endothelial growth factor

VIN vulval intraepithelial neoplasia

VRIII variable rate intravenous insulin infusion

VSCC vulvar squamous cell carcinoma

VSD ventricular septal defect

VTE venous thromboembolism

vWF von Willebrand factor

VZIG varicella zoster immunoglobulin

WCC white cell count

WHO World Health Organization

WLE wide local excision

Contributors

Editors

Sally Collins

Sabaratnam Arulkumaran

Professor of Obstetrics and Gynaecology, University of Nicosia Medical School, Cyprus, Professor Emeritus, St George’s, University of London, and Professor, Imperial College London, London, UK

Kevin Hayes

Consultant Obstetrician and Gynaecologist, St George’s University Hospital NHS Foundation Trust, London, UK

Kirana Arambage

Consultant Gynaecologist, John Radcliffe Hospital, Oxford, and Honorary Senior Clinical Lecturer, Nuffield Department of Women’s and Reproductive Health, University of Oxford, Oxford, UK

Lawrence Impey

Consultant Obstetrician and Subspecialist in Maternal and Fetal Medicine, John Radcliffe Hospital, Oxford, UK

Contributors to the fourth edition

W. Catarina Ang

Consultant Gynaecologist, Royal Women’s Hospital, Parkville, VIC, Australia

Chapter 2: Menopause

Ilyas Arshad

Consultant Gynaecologist, Liverpool University Hospitals NHS Trust, Liverpool, UK

Chapter 20: Contraception

Christian Becker

Associate Professor, Nuffield Department of Women’s and Reproductive Health, University of Oxford, Oxford, and Honorary Consultant Gynaecologist, Subspecialist in Reproductive Medicine and Surgery, John Radcliffe Hospital, Oxford, UK

Chapter 8: Subfertility and reproductive medicine

Charlotte Bennett

Consultant Neonatologist, Oxford University Hospitals NHS Foundation Trust, Oxford, UK

Chapter 8: Neonatal resuscitation

Abigail Brempah

Specialty Trainee in Obstetrics and Gynaecology, Lewisham and Greenwich NHS Trust, London, UK

Chapter 4: Gynaecological anatomy and development; Chapter 5: Normal menstruation and its disorders; Chapter 6: Early pregnancy problems; and Chapter 24: Miscellaneous gynaecology

Sarah Coleridge

Subspeciality Trainee in Gynaecological Oncology, Nottingham University Hospitals Trust, Nottingham, UK

Chapter 23: Benign and malignant gynaecological conditions

Ruth Curry

Consultant Obstetrician and Subspecialist in Maternal and Fetal Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK

Chapter 2: Benign and malignant tumours in pregnancy

Charlotte Frise

Consultant Obstetric Physician, Queen Charlotte’s and Chelsea Hospital, Imperial College

Healthcare NHS Trust, London, UK, and Lead Consultant Obstetric Physician for NW London

Chapter 5: Medical disorders in pregnancy

Suni Halder

Consultant Obstetric Anaesthetist, Oxford University Hospitals NHS Foundation Trust, Oxford, UK

Chapter 7: Obstetric anaesthesia

Rumana Islam

Consultant Gynaecologist, Barts

Health NHS Trust, London, UK

Chapter 8: Subfertility and reproductive medicine

Helen Jefferis

Consultant Gynaecologist/ Urogynaecologist, John Radcliffe Hospital, Oxford, UK

Chapter 22: Urogynaecology

Shamitha Kathurusinghe

Consultant Gynaecologist, Royal Women’s Hospital, Parkville, VIC, Australia

Chapter 2: Menopause

Bryn Kemp

Consultant Obstetrician and Maternal Medicine Lead, Royal Berkshire NHS Foundation Trust, Reading, UK

Chapter : Maternal and perinatal mortality

Kimmee Khan

Specialty Trainee in Obstetrics and Gynaecology, Epsom and St Helier University Hospitals NHS Trust, London, UK

Chapter 4: Gynaecological anatomy and development; Chapter 5: Normal menstruation and its disorders; Chapter 6: Early pregnancy problems; Chapter 9: Sexual assault; and Chapter 24: Miscellaneous gynaecology

Vicky Minns

Specialty Trainee in Obstetrics and Gynaecology, Epsom and St Helier University Hospitals NHS Trust, London, UK

Chapter 4: Gynaecological anatomy and development; Chapter 5: Normal menstruation and its disorders; Chapter 6: Early pregnancy problems; and Chapter 24: Miscellaneous gynaecology

Jo Morrison

Consultant Gynaecological Oncologist, Musgrove Park Hospital, Somerset NHS Foundation Trust, Taunton, UK

Chapter 23: Benign and malignant gynaecological conditions

Sanyal Patel

Consultant Obstetrician and Gynaecologist, Milton Keynes University Hospital, Milton Keynes, UK

Chapter 4: Infectious diseases in pregnancy

Pathiraja Pubudu

Consultant Gynaecologist/ Gynaecological Oncologist, Addenbrooke’s Hospital, Cambridge, UK

Chapter 7: Genital tract infections and pelvic pain

Jane Reavey

Senior Registrar, John Radcliffe Hospital, Oxford, UK

Chapter 7: Genital tract infections and pelvic pain

Fevzi Shakir

Consultant Gynaecologist, Royal Free Hospital, London, UK

Chapter 20: Contraception

Jasmine Tay

Consultant Obstetrician and Subspecialist in Maternal Fetal Medicine, Queen Charlotte’s Hospital, Imperial College NHS Trust, London, UK

Chapter 5: Medical disorders in pregnancy

Katy Vincent

Associate Professor, Senior Fellow in Pain in Women and Honorary Consultant Gynaecologist, Nuffield Department of Women’s and Reproductive Health, University of Oxford, John Radcliffe Hospital, Oxford, UK

Chapter 7: Genital tract infections and pelvic pain

Dilip Visvanathan

Consultant Gynaecologist, Barts Health NHS Trust, London, UK

Chapter 7: Genital tract infections and pelvic pain

Michael Yousif

Consultant in Liaison Psychiatry, West Middlesex University Hospital, London, UK

Chapter 3: Substance misuse and psychiatric disorders

Contributors to the second and third editions

Miss Karolina Afors

St George’s Hospital, London, UK

Dr Christian Becker

John Radcliffe Hospital, Oxford, UK

Dr Amy Bennett

Department of Genitourinary Medicine, Oxford University Hospitals, NHS Trust, Oxford, UK

Mrs Rebecca Black

John Radcliffe Hospital, Oxford, UK

Dr Shabana Bora

St George’s Hospital, London, UK

Dr Brian Brady

John Radcliffe Hospital, Oxford, UK

Mr Paul Bulmer

St George’s Hospital, London, UK

Mr Edwin Chandraharan

St George’s Hospital, London, UK

Dr Noan-Minh Chau

Specialist Registrar Rotation in Medical Oncology, London Deanery, UK

Dr Mellisa Damodaram

Queen Charlotte’s and Chelsea Hospital, London, UK

Miss Claudine Domoney

Chelsea and Westminster Hospital, London, UK

Dr Stergios K. Doumouchtsis

St George’s Hospital, London, UK

Dr Suzy Elniel

Chelsea and Westminster Hospital, London, UK

Dr Cleave W. J. Gass

St George’s Hospital, London, UK

Dr Ingrid Granne

John Radcliffe Hospital, Oxford, UK

Miss Catherine Greenwood

John Radcliffe Hospital, Oxford, UK

Mr Manish Gupta

John Radcliffe Hospital, Oxford, UK

Miss Pauline Hurley

John Radcliffe Hospital, Oxford, UK

Dr Nia Jones

Queens Medical Centre, Nottingham, UK

Miss Brenda Kelly

John Radcliffe Hospital, Oxford, UK

Dr Nigel Kennea

St George’s Hospital, London, UK

Dr Andy Kent

St George’s Hospital, London, UK

Dr Su-Yen Khong

John Radcliffe Hospital, Oxford, UK

Dr Emma Kirk

St George’s Hospital, London, UK

Dr Samatha Low

Royal Berkshire Hospital, Reading, UK

Dr Jo Morrison

Musgrove Park Hospital, Taunton, UK

Dr Neelanjana Mukhopadhaya

St George’s Hospital, London, UK

Dr Faizah Mukri

Specialist Registrar Rotation, London Deanery, UK

Dr Santosh Pattnayak

St George’s Hospital, London, UK

Dr Natalia Price

John Radcliffe Hospital, Oxford, UK

Dr Aysha Qureshi

Royal United Hospital, Bath, UK

Dr Devanna Rajeswari

St George’s Hospital, London, UK

Dr Gowri Ramanathan

St George’s Hospital, London, UK

Dr Margaret Rees

John Radcliffe Hospital, Oxford, UK

Dr Jackie Sherrard

Department of Genitourinary Medicine, Oxford University

Hospitals NHS Trust, Oxford, UK

Dr Lisa Story

John Radcliffe Hospital, Oxford, UK

Ms Louise Strawbridge

University College London, London, UK

Mr Alex Swanton

Royal Berkshire Hospital, Reading, UK

Dr Linda Tan

St George’s Hospital, London, UK

Dr Katy Vincent

John Radcliffe Hospital, Oxford, UK

Miss Cara Williams

University College London Hospital, UK

Dr Niraj Yanamandra

St Peter’s Hospital, Chertsey, UK

Normal pregnancy

Obstetric history: current pregnancy 2

Obstetric history: other relevant features 4

Obstetric physical examination 6

Engagement of the fetal head 8

Female pelvis 0

Diameters of the female pelvis 2

Fetal head 4

Diameters and presenting parts of the fetal head 6

Placenta: early development 8

Placenta: later development 9

Placenta: circulation 20

Placenta: essential functions 22

Physiology of pregnancy: endocrine 24

Physiology of pregnancy: haemodynamics 26

Physiology of pregnancy: cardiorespiratory 27

Physiology of pregnancy: genital tract and breast 28

Physiology of pregnancy: other changes 30

Preparing for pregnancy 3

Supplements and lifestyle advice 32

General health check 34

Diagnosis of pregnancy 36

Dating of pregnancy 37

Ultrasound assessment of fetal growth 38

Booking visit 40

Antenatal care: planning 42

Antenatal care: routine blood tests 44

Antenatal care: specific blood tests 45

Antenatal care: preparing for delivery 46

Obstetric history: current pregnancy

Obstetric history taking has many features in common with most other sections of medicine, along with certain areas specific to the specialty. the basic framework can be easily learned; however, competence requires good clinical knowledge and a lot of practice. As obstetrics often requires intimate examination and discussion of sensitive information, it is important to ensure privacy, and to demonstrate respect and confidentiality. It is important to offer a health professional as a chaperone. translation may be required and it is best to have an official translator as a family member, especially the husband/partner, translating may not divulge or may distort certain information. It is also important to ask about domestic violence when the mother is alone and offer help if appropriate.

A carefully obtained history taken in a logical sequence avoids inadvertent omission of important details, and guides the examination to follow.

Current pregnancy

Much of this information will be contained in the patient’s ‘hand-held’ notes:

• Name.

• Age.

• Occupation.

• relationship status.

• Gravidity (i.e. number of pregnancies, including the current one).

• Parity (i.e. number of births beyond 24wks gestation).

the expected date of delivery (EDD) can be calculated from the last menstrual period (LMP) using Naegele’s rule (add yr and 7 days to the LMP and subtract 3mths), most often done with an obstetric calendar (‘wheel’). Enquire about details that may affect the validity of the patient’s EDD as calculated from her LMP including:

• Long cycles.

• Irregular periods.

• recent use of the combined oral contraceptive pill (COCP).

2 Dating scans between 8 and 3wks are more reliable than LMP and should be used to provide an EDD where possible. Enquire about the current pregnancy, including:

• General health (tiredness, malaise, and other non-specific symptoms).

• If >20wks, enquire about fetal movements (FM).

• General details of pregnancy to date (previous admissions and current problems).

• results of all antenatal (AN) blood tests—routine and specific.

• results of anomaly and other scans (details of results can be crosschecked with the notes).

• If she is postnatal:

• labour and delivery

• history of the postnatal period.

An obstetric history

Should include:

• Current pregnancy details.

• Past obstetric history.

• Past gynaecological history.

• Past medical and surgical history.

• Drug history and allergies.

• Social history, including:

• recreational drug use

• domestic violence

• psychiatric illness especially in the postnatal period.

• Family history especially with regard to:

• multiple pregnancy

• diabetes

• hypertension

• chromosomal or congenital malformations.

Gravidity and parity explained the terminology used is gravida x, para a+b:

• x is the total number of pregnancies (including this one).

• a is the number of births beyond 24wks gestation.

• b is the number of miscarriages or termination of pregnancies before 24wks gestation.

Example

A woman who is pregnant for the 4th time with  normal delivery at term,  termination at 9wks, and  miscarriage at 6wks would be gravida 4, para +2.

Obstetric history: other relevant features

2 history often repeats itself, so previous AN, intrapartum, or postpartum complications should influence the management of this pregnancy.

Past obstetric history includes:

• Details of all previous pregnancies (including miscarriages and terminations).

• Length of gestation.

• Date and place of delivery.

• Onset of labour (including details of induction of labour).

• Mode of delivery.

• Sex and birth weight.

• Fetal and neonatal life.

• Clear details of any complications or adverse outcomes (such as shoulder dystocia, postpartum haemorrhage, or stillbirth).

Past gynaecological/medical/surgical history

• Method of contraception before conception.

• Previous gynaecological conditions/procedures.

• Cervical smear history.

• Medical conditions, such as hypertension, epilepsy, or diabetes.

• Details of any consultations with other physicians (neurologist or endocrinologist, psychiatrists).

• Involvement of any multidisciplinary teams (MDts).

• Details of any previous surgery.

Drug and allergy history

• Current medications.

• Medications taken at any time during the pregnancy.

• Any allergies and their severity (anaphylaxis or a rash?).

Family history

Any history of hereditary illnesses or congenital defects is important and is required to ensure adequate counselling and screening is offered.

• Familial disorders such as thrombophilias.

• Previously affected pregnancies with any chromosomal or genetic disorders, hypertensive disorders, early pregnancy loss, or preterm delivery.

• Consanguinity.

Social history

• Smoking.

• history of drug or alcohol abuse (E Chapter 3).

• Plans for breast-feeding.

• Social aspects, such as plans for childcare arrangements.

• Domestic violence screening.

Obstetric physical examination

At initial visit, a complete physical examination should be undertaken.

Abdominal examination: inspection

• Note the apparent size of the abdominal distension.

• Note any asymmetry.

• FM.

• Cutaneous signs of pregnancy:

• linea nigra (dark pigmented line stretching from the xiphisternum through the umbilicus to the suprapubic area)

• striae gravidarum (recent stretch marks are purplish in colour)

• striae albicans (old stretch marks are silvery-white)

• flattening/eversion of umbilicus (due to i intra-abdominal pressure).

• Superficial veins (alternative paths of venous drainage due to pressure on the inferior vena cava by a gravid uterus).

• Surgical scars (a low Pfannenstiel incision may be obscured by pubic hair, and laparoscopy scars hidden within the umbilicus).

Abdominal examination: palpation

• Symphysis fundal height (SFh):

• palpated <20wks

• measured in centimetres >20wks.

• Estimation of number of fetuses: multiple fetal poles.

• Fetal lie (relationship of longitudinal axis of fetus to that of the uterus):

• longitudinal fetal head or breech palpable over pelvic inlet

• oblique the head or breech is palpable in the iliac fossa and nothing felt in the lower uterus

• transverse fetal poles felt in flanks and nothing above the brim.

• Presentation (part of the fetus overlying the pelvic brim):

• cephalic (this could be vertex, face, or brow presentations determined vaginally)

• breech

• other (shoulder, compound).

• Amniotic fluid volume:

• i tense abdomen with fetal parts not easily palpated

• d compact abdomen with fetal parts easily palpable.

Auscultation of the fetal heart

the fetal heart (Fh) is best heard at the anterior shoulder of the fetus:

• A Doppler ultrasound device (Sonicaid) from about 2wks gestation.

• A fetal stethoscope (Pinard) from about 24wks gestation.

• In a breech presentation it is often heard at, or above, the level of the maternal umbilicus.

• r ate and the rhythm of the Fh should be determined over min.

• the recent National Institute for health and Care Excellence (NICE) guidelines raise the need for routine fetal heart rate (Fhr) auscultation in the presence of FM; but mothers enjoy listening to the Fh.

General examination

• Body mass index (BMI) calculated [weight (kg)/height (m)2].

2 Pregnancy complications are i with a BMI <8.5 and >25.

• Blood pressure (BP) measured in the semi-recumbent position (45° tilt).

2 Use an appropriate size cuff; too small a cuff gives a falsely i BP.

• Auscultation of the heart and lungs:

• flow murmurs are common and are not significant

• cardiac murmurs may be detected for the st time.

• thyroid gland (exclude a goitre).

• Breasts (exclude any lumps).

• varicose veins and skeletal abnormalities (kyphosis or scoliosis): pregnancy associated with i lumbar lordosis: i lower backache.

Normal uterine size

• the uterus normally becomes palpable at 2wks gestation.

• It reaches the level of the umbilicus at 20wks gestation.

• It is at the xiphisternum at 36wks gestation.

Symphysis fundal height

2 the SFh detects ~40–60% of small for gestational age (SGA) fetuses. Uterine size is measured from the highest point of the fundus to the upper margin of the symphysis pubis (Fig. .).

Appropriate growth is usually estimated to be the number of wks gestation in centimetres (at 30wks the SFh should be 30 ± 2cm):

• ± 2cm from 20 until 36wks gestation.

• ± 3cm between 36 and 40wks.

• ± 4cm at 40wks.

40 weeks 36 weeks 22 weeks 16 weeks 12 weeks

Fig. . typical fundal heights at various stages of pregnancy. reproduced from Wyatt JP, Illingworth rN, Graham CA, et al. (eds) (2006). Oxford Handbook of Emergency Medicine. Oxford: OUP. By permission of Oxford University Press.