Practical Obstetrics 1st Edition

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Author
Dr. Joachim W. Dudenhausen, FRCOG Prof. Dr. med. Michael Obladen
Professor of Obstetrics and Gynecology Charité University Medicine Berlin
Weill Cornell Medical College Augustenburger Platz 1
Deputy Chief Medical Officer 13353 Berlin, Germany
Sidra Medical and Research Center
Qatar Foundation, POBox 26999 Translated by
Doha, State of Qatar Susan E. Travis
Mittenwalder Strasse 10
Professor and Chairman Emeritus
10961 Berlin, Germany
Department of Obstetrics
e-mail: [email protected]
Charité University Medicine Berlin
Augustenburger Platz 1
13353 Berlin, Germany
e-mail: [email protected]

The title is the english translation of “Praktische Geburtshilfe”, 21th edition by J. W. Dudenhausen, De Gruyter 2012.
The book has 501 figures and 38 tables.

ISBN 978-3-11-027593-3
e-ISBN (PDF) 978-3-11-027611-4
e-ISBN (EPUB) 978-3-11-038135-1

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data are available on the Internet at http://dnb.dnb.de.

© 2014 Walter de Gruyter GmbH, Berlin/Boston.

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I dedicate this English edition of Practical
Obstetrics to all women and their children,
with the hope of optimal care for all.
Joachim W. Dudenhausen
Preface
The objective of this book is to provide a source I received numerous tips and much advice
of aid for health care providers for mothers and from many colleagues and midwives. Thanks
their unborn or newborn child. With enthusi- to everyone of them. Professor Wolfgang Hen-
asm, I looked forward to the translation and rich, Director of the Department of Obstetrics,
adaptation of the 21st edition of the German Charité, University Medicine Berlin, helped me
textbook Praktische Geburtshilfe into English by supplying ultrasonographic illustrations
and its publication under the current title Prac- and Doppler flow patterns. Thanks to Dr. Ulrike
tical Obstetrics. The manuscript reflects the Mergner, Department for Radiology, Charité,
current state of the obstetrical and neonatal art University Medicine Berlin, for the MRIs of
in the globalized world of medicine. We were pregnant women.
keen to reach a balance between the science I would like to thank Simone Witzel and Britta
of medicine and practical patient care, prin- Nagl from De Gruyter Berlin/Boston for their
ciples of practice, policies, and regulation of assistance in accomplishing this task.
most professional and academic organizations, I would like to acknowledge the great contribu-
guidelines, and recommendations. tion and help of my wife Dr. Ria Dudenhausen.
I am very thankful to Sue Travis for the care-
Joachim W. Dudenhausen
ful translation of the German manuscript into
Doha / State of Qatar
English. I am indebted for advice from Dr. Paul
June 2014
Ogburn, New York and Doha, and Dr. Alfredo
Gei, Houston, and also from Lisa Austin, Chi-
cago and Doha, in the adaptation to American
policies and procedures.
Content
Preface | VII

1 Physiology | 1
1.1 The mature placenta | 5
1.1.1 Structure, function | 5
1.1.2 The placenta as an endocrine organ: hCG, hPL, progesterone, and estrogen | 7
1.2 Amniotic fluid, liquor amnii | 10
1.3 Embryonic and fetal development | 11
1.4 The maternal organism | 13

2 Diagnosis of pregnancy | 17
2.1 Early pregnancy | 17
2.2 Diagnosis of late pregnancy | 18

3 Prenatal care | 19
3.1 Prenatal checkup | 19
3.1.1 History | 19
3.1.2 Obstetric examination | 22
3.1.3 General examination | 32
3.1.4 Examination of the woman at risk | 35
3.1.5 Prenatal diagnosis of genetic defects | 61
3.2 Antenatal counseling | 65
3.2.1 Lifestyle | 68
3.2.2 Common pregnancy complaints | 69

4 Maternal disorders in pregnancy | 73

4.1 Pregnancy-specific disorders | 73
4.1.1 Hyperemesis gravidarum | 73
4.1.2 Cholestasis | 73
4.1.3 Pregnancy-induced hypertension (PIH), preeclampsia, eclampsia, HELLP
syndrome | 74
4.1.4 Dermatoses of pregnancy | 84
4.2 Disorders not specific to pregnancy | 84
4.2.1 Cardiac disease | 84
4.2.2 Pulmonary tuberculosis | 86
4.2.3 Pyelonephritis in pregnancy | 86
4.2.4 Diabetes mellitus | 87
4.2.5 Thrombophilia | 91
4.2.6 Thyroid disorders | 92
4.2.7 Acute abdomen | 93
X Content

4.2.8 Adnexal tumors | 95

4.2.9 Cervical cytology | 96

5 Problems in the second half of pregnancy | 99

5.1 Preterm birth (PTB) | 99
5.2 Premature rupture of membranes; chorioamnionitis | 105
5.3 Intrauterine growth restriction (IUGR) | 107
5.4 Postterm pregnancy | 108
5.5 Stillbirth | 109

6 Disorders of the fetus | 113

6.1 Hemolytic disease | 113
6.2 Fetal alloimmune thrombocytopenia | 118
6.3 Prenatal infections | 118
6.3.1 Prenatal rubella infection, congenital rubella syndrome | 119
6.3.2 Cytomegalovirus (CMV) | 121
6.3.3 Varicella-zoster-virus (VZV) | 122
6.3.4 Herpes simplex virus (HSV) | 123
6.3.5 Virus hepatitis | 125
6.3.6 Parvovirus B19 | 126
6.3.7 AIDS, HIV seropositivity | 127
6.3.8 Pregnancy and neonatal listeriosis | 129
6.3.9 Toxoplasmosis | 129
6.3.10 Syphilis | 132
6.3.11 Gonorrhea | 134
6.3.12 Vaccination in pregnancy | 136
6.4 Malformations | 136
6.4.1 Hydrocephalus | 136

7 Normal labor | 141

7.1 Birth factors | 141
7.1.1 Fetus | 141
7.1.2 Birth route | 143
7.1.3 Force of labor, contractions | 147
7.2 Mechanism of labor | 150
7.2.1 Signs, onset of labor, preparation for labor | 151
7.2.2 History taking, examination, spontaneous vaginal delivery | 152
7.2.3 Passage of the head through the birth canal | 155
7.2.4 Station. Level of the head in the pelvis | 162
7.3 Examination of the fetus during labor | 167
7.3.1 Auscultation, amniotic fluid color | 167
7.3.2 Cardiotocography (CTG), electronic fetal monitoring (EFM) | 168
 Content XI

7.3.3 Fetal blood sampling (FBS) | 177

7.4 Management of labor | 180
7.4.1 Management of first stage | 180
7.4.2 Management of second stage | 189
7.5 Management of third stage | 199
7.6 Postplacental period | 204
7.7 Duration of labor | 208

8 Pathological labor | 211

8.1 Malpresentations and malpositions of the occiput | 211
8.1.1 Persistent occipitotransverse position (POT) | 211
8.1.2 High anteroposterior head | 214
8.1.3 Occipitoposterior position | 215
8.1.4 Extended presentations | 220
8.2 Breech presentation | 233
8.2.1 Classification, diagnosis, differential diagnosis | 234
8.2.2 Mechanism of labor | 236
8.2.3 Antenatal counseling | 244
8.2.4 Mode and management of delivery | 245
8.3 Transverse lie/shoulder presentation | 264
8.3.1 Course of labor in transverse lie | 266
8.3.2 Management of transverse lie | 268
8.4 Multifetal gestations | 270
8.4.1 Antenatal care | 272
8.4.2 Birth complications, mode | 275
8.5 Pathological contractions, uterine dystocia | 278
8.6 Arrested labor | 280
8.7 Cervical priming and induction of labor | 282
8.8 Intrauterine (perinatal) hypoxia | 284
8.9 Cord complications: presentation, prolapse | 288
8.9.1 Cord presentation | 288
8.9.2 Cord prolapse | 288
8.10 Arm complications: Compound presentation, arm presentation, prolapse | 290
8.11 Shoulder dystocia | 292
8.12 Cephalopelvic disproportion (CPD) | 294
8.12.1 Generally contracted pelvis | 296
8.12.2 Funnel-shaped pelvis | 302
8.12.3 Long pelvis | 303
8.13 Uterine rupture | 306
8.14 Management of birth after prior cesarean section | 311
8.15 Amniotic fluid embolism (AFE) | 312
XII Content

9 Obstetrical operations | 315

9.1 Indication | 315
9.2 Preparation for the operation | 316
9.3 Episiotomy, perineotomy | 316
9.4 Laceration of the vagina, perineum, clitoris, labia | 320
9.5 Forceps operation | 322
9.6 Vacuum extraction, ventouse extraction (VE) | 332
9.7 Cesarean section | 335
9.8 Combined version | 340
9.8.1 Version from transverse lie | 340
9.8.2 Version from cephalic presentation | 343
9.9 Dismembering operations: perforation, cranioclasm | 343

10 Antepartum and postpartum hemorrhage | 351

10.1 Miscarriage, spontaneous abortion | 351
10.1.1 Induced abortion | 351
10.1.2 Spontaneous abortion | 352
10.2 Gestational trophoblastic disease (GTD) | 360
10.3 Ectopic pregnancy | 363
10.4 Placenta previa | 369
10.5 Placental abruption | 374
10.6 Velamentous insertion | 379
10.7 Postpartum hemorrhage (PPH) | 380
10.7.1 Separation hemorrhage, atonic PPH | 380
10.7.2 Hemorrhage from a laceration | 388

11 Normal puerperium | 391

11.1 Process of involution | 391
11.1.1 Position and attitude of the uterus in the puerperium | 392
11.1.2 Closure of the cervix | 392
11.1.3 Fundal height in the first days postpartum | 393
11.2 Wound-healing processes in the puerperium | 393
11.2.1 Lochia | 394
11.3 Lactation | 395
11.4 Resumption of ovarian function | 396
11.5 Clinical picture of the puerperal period | 397
11.5.1 The postpartum pulse | 397
11.5.2 Temperature postpartum | 398
11.5.3 Monitoring fundal height | 398
11.5.4 Monitoring lochia | 398
11.5.5 Micturition in early puerperium | 399
11.5.6 Bowel movements | 400
11.5.7 Postpartum exercises | 400
 Content XIII

11.5.8 Ambulation postpartum – early ambulation | 400

11.5.9 Discharge from hospital and the end of the clinical puerperium | 400
11.5.10 Breastfeeding | 401

12 Pathological puerperium | 405

12.1 Puerperal fever = childbed fever | 405
12.1.1 Localized puerperal infections | 406
12.1.2 Disseminated puerperal infection | 407
12.2 Hemorrhage in the puerperal period | 412
12.2.1 Retained placental tissue and placental polyp | 412
12.2.2 Puerperal endometritis | 413
12.2.3 Functional hemorrhage in the puerperium | 414
12.2.4 Bleeding from birth traumas in the puerperium | 414
12.3 Injury to the symphysis pubis | 414
12.4 Mastitis puerperalis | 416
12.5 Pelvic vein thrombosis | 420
12.6 Postpartum thyroiditis | 422
12.7 Psychiatric disorders | 422

M. Obladen
13 The newborn | 425
13.1 The healthy newborn | 425
13.1.1 The baby and its parents | 425
13.1.2 Initial care | 425
13.1.3 Examination | 426
13.1.4 Screening program | 428
13.1.5 Other preventative measures | 429
13.2 Diet and care | 429
13.2.1 Lactation, breastfeeding, medication in breast milk | 429
13.2.2 Dietary plan for artificial feeding | 431
13.2.3 Dietary disorders | 432
13.2.4 Care of the healthy newborn | 432
13.3 Postnatal adaptation | 433
13.3.1 Physiological adaptation | 433
13.3.2 Pathological adaptation | 438
13.4 Birth trauma | 443
13.5 The preterm baby | 446
13.5.1 Gestational age | 446
13.5.2 Complications | 446
13.5.3 Diseases of preterm babies | 447
13.6 Hypotrophic newborn | 451
13.7 The infant of the diabetic mother (IDM) | 452
13.7.1 Glucose metabolism and hypoglycemia | 452
XIV Content

13.7.2 Fetopathia diabetica and complications | 453

13.8 Common newborn diseases | 454
13.8.1 Respiratory disorders | 454
13.8.2 Anemia, polycythemia, hyperviscosity | 455
13.8.3 Hyperbilirubinemia, icterus, phototherapy | 456
13.8.4 Hemolytic disease (HD) | 457
13.8.5 Drug addiction, drug withdrawal | 459
13.8.6 Neonatal seizures | 459
13.9 Common congenital abnormalities | 459
13.9.1 Gastrointestinal tract | 460
13.9.2 Congenital cardiac malformations | 463
13.9.3 Skeletal malformations | 463
13.9.4 Down syndrome | 466
13.9.5 Alcohol embryopathy, -fetopathy (fetal alcohol syndrome; FAS) | 467
13.10 Neonatal infections | 468
13.10.1 Immune status of the neonate | 468
13.10.2 Sepsis and GBS infection | 468
13.10.3 Other vertical infections | 469
13.11 Level of Care and Regionalization | 470
13.11.1 Prenatal transfer to a perinatal center | 470
13.11.2 Neonatal consultation | 470
13.11.3 Indications for transfer to neonatal intensive care unit (NICU) | 471
13.11.4 Transfer to NICU not indicated | 471
13.11.5 Postnatal transport | 471

Index | 475
1 Physiology

Definitions – Conjugation. Fusion of the nuclei of sperm

Ovulation. Release of the ovum from the ovary and ovum; fusion of the chromosomes of
on day 14 of the menstrual cycle of a woman the pronuclei on day one-two. They line
of child-bearing age. The oocyte is flushed out up on the equatorial plane without fusing.
of the Graafian follicle with the follicular fluid Fertilization is now complete.
and consists of egg plasma with core, nucleo-
Cleavage. The development of grooves on the
lus, and zona pellucida. It is surrounded by
surface of the fertilized ovum, visible sign of
follicular epithelial cells (corona radiata) and
cell division on day two to three after concep-
enters the fallopian tube through the fimbrial
tion. Continued cell division results in the cre-
end. The passage of the ovum through the fal-
ation of many daughter cells.
lopian tube into the uterus takes five days.
Morula (Latin for mulberry). A ball of daughter
Copulation. Sexual intercourse, cohabitation,
cells or blastomeres, reaching the 16-cell stage
coitus; copulation is coitus performed for the
on day three to five.
purpose of reproduction. The ejaculate (ap-
prox. 4 ml), containing 200 million sperm, is Blastocyst. Conceptus, product of conception.
deposited in the posterior fornix. From there On day five the intercellular spaces enlarge and
the sperm swim through the cervical mucus cavitation occurs, resulting in the creation of
and the uterus to the entrance of the fallopian the blastocyst cavity. The morula becomes the
tube. blastocyst, consisting of the trophoblast, the
outer cell layer, which develops into the cho-
Conception. Coitus resulting in fertilization;
rionic epithelium (the fetal epithelium part of
fusion of ovum and spermatozoa in the am-
the placenta), and the embryoblast, or inner
pulla of the fallopian tube.
cell mass. The embryoblast develops into the
Extrauterine fertilization (such as in the ab- embryo, amnion, yolk sac, allantois, and the
domen, the ovary or a section of the fallopian chorionic mesoderm (fetal connective tissue
tube) may occur in cases of abnormal transport part of the placenta).
of the ovum to the uterine cavity.
Nidation, implantation. The blastocyst em-
Fertile period. The oocytes remain fertile for beds itself in the endometrial wall of the uterus
six to eight hours. Sperm can live for up to two (decidua), which has been prepared for the
days. The fertile period of the menstrual cycle pregnancy, on day six or seven after lysis of the
is four days. zona pellucida has occurred.

There are two fertile phases: impregnation Microvilli emerge from the endometrial cells
and conjugation and transform into smooth epithelial cells of the
– Impregnation (Fig. 1.1). The sperm pen- uterus (pinopods). These cells increase in size
etrates the ripe ovum, thus creating a through the absorption of fluids from the uter-
fertilized cell (zygote). The egg cytoplasm ine cavity and the influence of progesterone.
shrinks as a result of the sperm penetration, Estrogens stimulate the release of the adhesive
creating the perivitelline space between the molecule Mucin 1, which facilitates the implan-
zona pellucida and the ooplasm. tation of the blastocyst. The invasion of the im-
2 1 Physiology

Blastocyst

Myometrium

Decidua

Fimbrian end of the Fallopian tube

Fig. 1.1: Development of the fertilized ovum before implantation.

planted blastocyst is directed by interleukins, (cytotrophoblast, Langhans cell layer). Finger-

cytokines, and interferons. This leads to a pro- like projections grow from the cytotrophoblast
duction cascade of vascular endothelial growth into the syncytium, forming the primary cho-
factor (VEGF), nitric oxide, and prostacyclins. rionic villi.

Invading trophoblast. The cells of the im- Amniotic cavity. A gap forms in the origi-
planted trophoblast surrounding the embryo- nally solid embryoblast. The base of this gap is
blast erode the uterine epithelium with the formed by the epiblast; the top by the amniotic
help of enzymes, allowing it to embed in the layer of the embryoblast (hypoblast).
endometrium, where rapid cell proliferation
Formation of the germ layers (Fig. 1.2). The
occurs. Some of the substances released in the
embryonic shield differentiates into the three
process nourish the conceptus (histiotrophic
germ layers: ectoderm, endoderm, and meso-
phase). Numerous maternal blood vessels are
derm.
eroded, and the first contact with maternal
– The ectodermal layer gives rise to the
blood occurs. In this way the primitive mater-
nervous system, skin, hair, nails, eyes, and
nal intervillous capillary system is constructed
ears.
within the trophoblast. The histiotrophic phase
– The mesodermal layer gives rise to bones,
is completed on days nine to twelve, and the
muscles, connective tissue, vessels, and the
hemotrophic phase begins.
urogenital system.
Absorption trophoblast. Differentiation of – The endodermal layer gives rise to the gas-
the trophoblast; the intercellular boundar- trointestinal tract, liver, bile system, pan-
ies fuse in the peripheral trophoblastic cells, creas, thyroid, and lungs. The endoderm
forming the syncytium (syncytiotrophoblast), grows over the edge of the embryoblast into
while the inner trophoblastic cells (those clos- the inner cytotrophoblast until it surrounds
est to the embryo) retain their cellular form a cavity: the yolk sac.
 1 Physiology 3

Somatic mesoderm Chorion

Amniotic cavity
Gut
Splanchnic mesoderm Amnion
Embryo

Coelom
Allantois
Yolk sac Entoderm

Placenta

Fig. 1.2: Embryo three weeks after conception.

Extraembryonic mesoderm. Reticulum-like trium, secreting an extra-cellular matrix

tissue which develops from the cells surround- which anchors the placenta in the decidua.
ing the embryoblast. In the 15-day-old embryo They cause endothelial swelling in the
it covers the two close vesicles: the amniotic spiral arterioles, edema, and a reduction of
cavity and the yolk sac. It thickens to make up elasticity.
the chorion (somatic mesoderm) on the inner – Endovascular invasion. From week 10, tro-
side of the trophoblast and on the outer side of phoblasts are found in place of the intima
the embryo the amnion, (sphlanchnic meso- and in the media of the spiral arterioles.
derm). This results in a pronounced vascular dila-
tion, and thus an increase in the uteropla-
Body stalk. Mesenchymal strand at the cau-
cental blood flow.
dal end of the embryo, connecting chorion
and amnion, later developing into the umbili-
cal cord. The first blood vessels develop in the Development of the chorionic villi
body stalk and in the mesoderm (blood islands Syncytial trabeculae border on blood-filled
and cells) on week three of embryonic devel- lacunae through which maternal blood flows
opment. The allantois follows, as part of the in week 4. From these originate:
developing hindgut. During this rudimentary – Trabeculae. Radially arranged chorionic
development, the blood vessels of the allantois villi.
penetrate the body stalk and later become the – Primary villi. Only epithelial cells. In week
umbilical vessels. 4, cytotrophoblast cells grow into the inner
trabeculae, which are overlaid with syncy-
Trophoblast invasion. Trophoblastic cells
tial cells and have a cytotrophoblast core.
migrate into the decidua and the inner third
of the myometrium to anchor the placenta and Mesenchymal cells have grown into the tropho-
increase uteroplacental perfusion by remodel- blast and transformed primary into secondary
ing the spiral arterioles. These trophoblastic villi.
cells are known as extravillous trophoblasts (in – Secondary villi. Epithelial and connective
contrast to the villous trophoblast = placental tissue (= chorionic villi). They develop
villi). Extravillous trophoblasts take one of two when extraembryonic mesoderm penetrates
paths: the cytotrophoblast. From outer to inner
– Interstitial invasion. Trophoblasts migrate layers: syncytium, cytotrophoblast, basal
from the villi into the decidua and myome- membrane, chorionic mesoderm.
4 1 Physiology

a b c

Fig. 1.3: Villous reduction and vascularization in pregnancy; (a) immature villus, week 16; (b) immature villus,
week 24; (c) mesh of mature villi. Seven villi, interconnected by intervillous bridges, now occupy the same space.
The widened capillaries (sinusoids) have displaced the villous stroma (after Becker).

Fig. 1.4: Fetal and placental development 10 weeks after LMP.

– Tertiary villi. Contain blood vessels. Extra- gestational week to 50 μm in the last weeks of
embryonic blood vessels are present in the pregnancy. The continuous decrease in villous
mesodermal nucleus from week 5. Once volume goes hand-in-hand with the develop-
those vessels connect with the fetal circu- ment of the villous vessels (Fig. 1.3). The villi
latory system in week 6, substances are mature, adapting to the nutritional require-
transported in the blood from placenta to ments of the fetus. The distance covered by
the embryo, replacing diffusion, which was the substances being exchanged (diffusion be-
the main transport method until this time. tween maternal and fetal blood = thickness of
the syncytiocapillary membrane) grows smaller.
By week 14 of gestation the placenta has
The outer layer of the two-layered chorionic ep-
reached its definitive form. Continuing devel-
ithelium (syncytium and Langhans cell layer)
opment takes the form of an increase in diam-
contains plasma projections (microvilli) which
eter and a decrease of the distance between the
increase the surface area of the syncytiocapil-
intervillous spaces.
lary membrane.

Villi. The villi decrease in diameter through- The inner surface area of the mature placenta
out the pregnancy, from 140 μm in the first amounts to 12–13 m².