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South Asian Edition of
THE JOHNS HOPKINS
MANUAL OF GYNECOLOGY
AND OBSTETRICS
Sixth Edition
South Asian Edition of
THE JOHNS HOPKINS
MANUAL OF GYNECOLOGY
AND OBSTETRICS
Sixth Edition
Betty Chou, md
Residency Program Director
Assistant Professor
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine
Baltimore, Maryland
Jessica L. Bienstock, md, mph

Associate Dean for Graduate Medical Education and
Designated Institutional Official
Vice Chair for Education
Professor, Maternal Fetal Medicine
Baltimore, Maryland
Andrew J. Satin, md
The Dr. Dorothy Edwards Professor and
Director (Chair) of Gynecology and Obstetrics
Obstetrician/Gynecologist-in-Chief
Johns Hopkins Medicine
Baltimore, Maryland
Sixth edition
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This Manual is not intended to substitute for the
independent professional judgment of the patient’s
treating clinicians, nor should it be considered a
statement of the standard of care. This Manual is
designed as an educational resource only. Use of this
information is voluntary. This Manual should not be
considered as inclusive of all appropriate treatments or
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of available resources, advances in knowledge or
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not guarantee, warrant, or endorse the products or
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Dedication
We have dedicated previous editions to our mentors, mentees, and loved ones who
energize and inspire us. We would be remiss not to recognize those groups again.
We are honored to continue the tradition of this manual, to work with dedicated
colleagues at Johns Hopkins and beyond, all in an effort to advance the health of
women and families.
Andrew J. Satin, MD
Jessica Bienstock, MD, MPH
Betty Chou, MD
vii
Preface
The history of the Department of Gynecology and Obstetrics extends over 130 years.
We are very proud of our historic tradition of leadership in gynecology, obstetrics,
and our subspecialties, dating back to Drs. Howard Kelly, J.W. Williams, Richard
TeLinde, Nicholson Eastman, Howard and Georgeanna Jones, and so many others
who have come before us. Our proud tradition inspires us today to advance our tri-
partite mission of clinical care, research, and education. In an era of economic and
market challenges to academic medicine, we remain steadfast to ensuring advances in
all arms of our tripartite mission. Now in its sixth edition, this manual continues to
be created by the cooperative efforts of a resident or fellow, faculty preceptor, and a
senior faculty editor at Johns Hopkins. It draws its strength from the collaboration
of experienced faculty and insightful practical input from rising stars in our field. In
using this edition, we hope you will appreciate the camaraderie in which the manual
was created. This manual is truly a team effort. Over the years, this book has been a
trusted companion carried in the lab coats of residents, medical students, and busy
clinicians.
This edition contains several new chapters addressing contemporary topics affect-
ing our patients. Substance abuse, specifically opioid use, in pregnancy has escalated
dramatically in recent years. The rise of fetal therapy programs including management
options for twin-to-twin transfusion led us to expand content on multifetal gestation.
The recognition of the role of genetics prompted a new chapter on genetic and hered-
itary syndromes. In addition to new chapters in obstetrics addressing substance abuse
and multifetal gestation we added chapters on psychiatric disorders, dermatologic
disease, and neoplastic disease in pregnancy. New gynecologic chapters focus on organ
prolapse, incontinence, and benign vulvar disease. Emphasis on safety sciences and
value-based care is pervasive in modern medicine and is now incorporated throughout
the practice of obstetricians and gynecologists. We dedicate a new chapter in this edi-
tion of the manual to this most important topic. As much as things change, we hope
and trust that the content, readability, portability, format, and size continue to have
great appeal for practicing clinicians and learners.
Andrew J. Satin, MD
Jessica Bienstock, MD, MPH
Betty Chou, MD
Online resources are not available with this text.
ix
Contributors
All chapter first authors are current or former residents/clinical fellows of the Johns
Hopkins Department of Gynecology and Obstetrics. All chapter senior authors are
current or former faculty of the Johns Hopkins University School of Medicine.
Crystal Aguh, MD Deborah K. Armstrong, MD

Director, Ethnic Skin Fellowship Professor, Department of Oncology
Assistant Professor Professor, Department of Gynecology and
Johns Hopkins University School of Medicine Obstetrics
Baltimore, Maryland Johns Hopkins University School of Medicine
Baltimore, Maryland
Abimbola Aina-Mumuney, MD
Assistant Professor Ahmet Baschat, MD
Division of Maternal Fetal Medicine Professor
Department of Gynecology and Obstetrics Director, Johns Hopkins Center for Fetal
Johns Hopkins University School of Medicine Therapy
Baltimore, Maryland Department of Gynecology and Obstetrics
Steve C. Amaefuna, MD Baltimore, Maryland
Resident Physician
Department of Gynecology and Obstetrics Anna L. Beavis, MD, MPH
Johns Hopkins University School of Medicine Assistant Professor
Baltimore, Maryland Kelly Gynecologic Oncology Service
Jean R. Anderson, MD Johns Hopkins University School of Medicine
Professor Baltimore, Maryland
Johns Hopkins University School of Medicine Jessica L. Bienstock, MD, MPH
Baltimore, Maryland Associate Dean for Graduate Medical
Education and Designated Institutional
Ana M. Angarita, MD Official
Resident Physician Vice Chair for Education
Department of Gynecology and Obstetrics Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine Professor, Maternal Fetal Medicine
Baltimore, Maryland
Maria Facadio Antero, MD
Clinical Fellow, Female Pelvic Medicine and Juliet C. Bishop, MD
Reconstructive Surgery Clinical Fellow, Maternal Fetal Medicine/
Department of Gynecology and Obstetrics Genetics
Johns Hopkins University School of Medicine Department of Gynecology and Obstetrics
Baltimore, Maryland
Cynthia H. Argani, MD
Assistant Professor Mostafa A. Borahay, MD, MPH
Department of Gynecology and Obstetrics Associate Professor
Baltimore, Maryland
xi
xii CONTRIBUTORS
Carla Bossano, MD Jensara Clay, MD

Assistant Professor Assistant Professor
Johns Hopkins University School of Medicine Johns Hopkins University School of Medicine
Baltimore, Maryland Baltimore, Maryland
Irina Burd, MD, PhD Jenell S. Coleman, MD, MPH

Associate Professor Associate Professor
Director, Maternal Fetal Medicine Division Director, Gynecologic Specialties
Fellowship Medical Director, JHOC Women’s Health
Department of Gynecology and Obstetrics Center
Baltimore, Maryland
Kamaria C. Cayton Vaught, MD
Clinical Fellow, Reproductive Endocrinology, Chantel I. Cross, MD
Infertility, and Genetics Assistant Professor
Danielle B. Chau, MD Kristin Darwin, MD

Resident Physician Resident Physician
Katherine F. Chaves, MD Samantha de los Reyes, MD

Resident Physician Clinical Fellow, Maternal Fetal Medicine
Johns Hopkins University School of Medicine University of Chicago
Baltimore, Maryland Chicago, Illinois
Chi Chiung Grace Chen, MD, MHS Rita W. Driggers, MD

Associate Professor Associate Professor
Mindy S. Christianson, MD Jill Edwardson, MD, MPH

Medical Director, Johns Hopkins Fertility Division of Family Planning
Center Department of Gynecology and Obstetrics
Department of Gynecology and Obstetrics Johns Hopkins University School of Medicine
Johns Hopkins University School of Medicine Baltimore, Maryland
Baltimore, Maryland
CONTRIBUTORS xiii
Cybill R. Esguerra, MD Stéphanie Gaillard, MD, PhD
Department of Gynecology and Obstetrics Department of Oncology and Gynecology/
Johns Hopkins University School of Medicine Obstetrics
Baltimore, Maryland
Amanda Nickles Fader, MD
Associate Professor Nicole R. Gavin, MD
Chief, Vice Chair of Gynecology Surgery Clinical Fellow, Maternal Fetal Medicine
Operations Department of Gynecology and Obstetrics
Director, Center for Rare Gynecologic Johns Hopkins University School of Medicine
Cancers Baltimore, Maryland
Kelly Gynecologic Oncology Service
Johns Hopkins University School of Medicine Megan E. Gornet, MD
Baltimore, Maryland Resident Physician
Tola Fashokun, MD Johns Hopkins University School of Medicine
Medical Student Instructor Baltimore, Maryland
Department of Obstetrics and Gynecology
Johns Hopkins University School of Medicine Ernest M. Graham, MD
Baltimore, Maryland Professor
Jerome J. Federspiel, MD, PhD Johns Hopkins University School of Medicine
Clinical Fellow, Maternal Fetal Medicine Baltimore, Maryland
Duke University Marielle S. Gross, MD, MBE
Durham, North Carolina Hecht-Levi Postdoctoral Fellow
Berman Institute of Bioethics
Braxton Forde, MD Johns Hopkins University Bloomberg School
Clinical Fellow, Maternal Fetal Medicine of Public Health
Department of Obstetrics and Gynecology Baltimore, Maryland
University of Cincinnati Medical Center
Cincinnati, Ohio Marlena Simpson Halstead, MD
Physician
Anja Frost, MD Complete Care for Women
Resident Physician Department of Obstetrics and Gynecology
Department of Gynecology and Obstetrics Chippenham Hospital
Johns Hopkins University School of Medicine Richmond, Virginia
Baltimore, Maryland
Esther S. Han, MD, MPH
Timothee Fruhauf, MD, MPH Clinical Fellow, Minimally Invasive
Resident Physician Gynecologic Surgery
Department of Gynecology and Obstetrics Columbia University Medical Center
Johns Hopkins University School of Medicine New York-Presbyterian Hospital
Baltimore, Maryland New York, New York
xiv CONTRIBUTORS
Katerina Hoyt, MD Chavi Kahn, MD, MPH

Resident Physician Physician
Department of Gynecology and Obstetrics Planned Parenthood of Maryland
Baltimore, Maryland
Edward K. Kim, MD, MPH
Nancy A. Hueppchen, MD, MSc Resident Physician
Associate Professor Department of Gynecology and Obstetrics
Associate Dean, Undergraduate Medical Johns Hopkins University School of Medicine
Education Baltimore, Maryland
Division of Maternal-Fetal Medicine
Department of Gynecology and Obstetrics Benjamin K. Kogutt, MD
Johns Hopkins University School of Medicine Clinical Fellow, Maternal Fetal Medicine
Tochi Ibekwe, MD Baltimore, Maryland
Instructor
Department of Gynecology and Obstetrics Jaden R. Kohn, MD, MPH
Johns Hopkins University School of Medicine Resident Physician
Johns Hopkins Hospital
Angie C. Jelin, MD Baltimore, Maryland
Assistant Professor, Maternal Fetal Medicine/
Genetics Lauren M. Kucirka, MD, PhD
Department of Gynecology and Obstetrics Resident Physician
Baltimore, Maryland
Clark T. Johnson, MD, MPH
Assistant Professor Megan E. Lander, MD
Baltimore, Maryland
Tiffany Nicole Jones, MD, MS
Resident Physician Shari M. Lawson, MD, MBA
Department of Gynecology and Obstetrics Assistant Professor
Johns Hopkins University School of Medicine Division Director, Generalist Obstetrics and
Baltimore, Maryland Gynecology
Svena D. Julien, MD Johns Hopkins University School of Medicine
Assistant Professor Baltimore, Maryland
Division of Maternal Fetal Medicine
Department of Gynecology and Obstetrics Jessica K. Lee, MD, MPH
Johns Hopkins University School of Medicine Assistant Professor
Baltimore, Maryland Department of Obstetrics, Gynecology and
Reproductive Sciences
University of Maryland School of Medicine
Baltimore, Maryland
CONTRIBUTORS xv
Judy M. Lee, MD, MPH, MBA Morgan Mandigo, MD, MSc
Adjunct Assistant Professor, Division of Obstetrician/Gynecologist
Gynecologic Specialties York Hospital
Department of Gynecology and Obstetrics York, Maine
Baltimore, Maryland Melissa Pritchard McHale, MD
Resident Physician
Kristen Ann Lee, MD Department of Gynecology and Obstetrics
Resident Physician Johns Hopkins University School of Medicine
Department of Gynecology and Obstetrics Baltimore, Maryland
Baltimore, Maryland Meghan McMahon, MD
Resident Physician
Kimberly Levinson, MD, MPH Department of Gynecology and Obstetrics
Assistant Professor Johns Hopkins Hospital
Baltimore, Maryland Lorraine A. Milio, MD
Assistant Professor
Melissa H. Lippitt, MD, MPH Department of Gynecology and Obstetrics
Clinical Fellow, Gynecology Oncology Johns Hopkins University School of Medicine
Baltimore, Maryland Christina N. Cordeiro Mitchell, MD
Clinical Fellow, Reproductive,
David A. Lovejoy, MD Endocrinology, and Infertility
Associate Professor Department of Gynecology and Obstetrics
Department of Obstetrics and Gynecology Johns Hopkins University School of Medicine
Mercer University School of Medicine Baltimore, Maryland
Macon, Georgia
Bernard D. Morris III, MD
Jacqueline Y. Maher, MD Resident Physician
Assistant Research Physician and Staff Department of Gynecology and Obstetrics
Clinician Johns Hopkins University School of Medicine
Division of Pediatric and Adolescent Baltimore, Maryland
Gynecology
Division of Reproductive Endocrinology and Chailee Faythe Moss, MD
Infertility Assistant Professor
Eunice Kennedy Shriver National Institute Department of Gynecology and Obstetrics
of Child Health and Human Development Johns Hopkins University School of Medicine
(NICHD) Baltimore, Maryland
Bethesda, MD
Reneé Franklin Moss, MD
Amanda C. Mahle, MD, PhD Resident Physician
Resident Physician Department of Gynecology and Obstetrics
Baltimore, Maryland
xvi CONTRIBUTORS
Lea A. Moukarzel, MD Elizabeth Oler, MD

Clinical Fellow, Gynecology Oncology Physician and Surgeon
Department of Surgery Department of Obstetrics and Gynecology
Memorial Sloan Kettering Cancer Center Evergreen Women’s Health
New York, New York Roseburg, Oregon
Jamie Murphy, MD Lauren M. Osborne, MD

Associate Professor Assistant Professor
Director of Obstetrics, Gynecology and Fetal Departments of Psychiatry and Behavioral
Anesthesiology Division Sciences
Department of Anesthesiology and Critical Department of Gynecology and Obstetrics
Care Medicine Johns Hopkins University School of Medicine
Baltimore, Maryland
Yangshu Linda Pan, MD
Emily Myer, MD Resident Physician
Urogynecologist Department of Gynecology and Obstetrics
Department of Obstetrics and Gynecology Johns Hopkins Hospital
Minnesota Women’s Care Baltimore, Maryland
Woodbury, Minnesota
Prerna Raj Pandya, MD, MS
Shriddha Nayak, MD Clinical Fellow, Female Pelvic Medicine and
Assistant Professor Reconstructive Surgery
Victoire Ndong, MD Silka Patel, MD, MPH

Resident Physician Assistant Professor
Donna Maria Neale, MD Kristin Patzkowsky, MD

Christopher M. Novak, MD Jennifer A. Robinson, MD, MPH,

Assistant Professor PhD
Department of Gynecology and Obstetrics Assistant Professor
Baltimore, Maryland
CONTRIBUTORS xvii
Linda C. Rogers, CRNP Khara M. Simpson, MD
Nurse Practitioner Assistant Professor
Johns Hopkins Bayview Medical Center Department of Gynecology and Obstetrics
Baltimore, Maryland
Isa Ryan, MD
Resident Physician Anna Jo Smith, MD, MPH, MSc
Baltimore, Maryland
Brittany L. Schuh, MD
Resident Physician Malorie Snider, MD
Department of Gynecology and Obstetrics Attending Physician
Johns Hopkins University School of Medicine Department of Obstetrics and Gynecology
Baltimore, Maryland Tanner Clinic
Layton, Utah
Marla Scott, MD
Clinical Fellow, Gynecology Oncology Rebecca Stone, MD, MS
Cedars-Sinai Medical Center Associate Professor
Los Angeles, California Division Director, Kelly Gynecologic
Oncology Service
Rachel Chan Seay, MD Department of Gynecology and Obstetrics
Assistant Professor Johns Hopkins University School of Medicine
Baltimore, Maryland Carolyn Sufrin, MD, PhD
Assistant Professor
Angela K. Shaddeau, MD, MS Division of Family Planning
Clinical Fellow, Maternal Fetal Medicine Department of Gynecology and Obstetrics
Baltimore, Maryland
Stacy Sun, MD, MPH
Jeanne S. Sheffield, MD Clinical Fellow, Family Planning
Professor Department of Gynecology and Obstetrics
Division Director, Maternal Fetal Medicine Johns Hopkins University School of Medicine
Baltimore, Maryland Sunitha Suresh, MD
Clinical Fellow, Maternal Fetal Medicine
Wen Shen, MD, MPH Department of Obstetrics and Gynecology
Assistant Professor University of Chicago
Department of Gynecology and Obstetrics Chicago, Illinois
Baltimore, Maryland Edward J. Tanner III, MD
Associate Professor
Northwestern University
Chicago, Illinois
xviii CONTRIBUTORS
Lauren Thomaier, MD Karen C. Wang, MD

Clinical Fellow, Gynecology Oncology Assistant Professor
Department of Obstetrics, Gynecology and Department of Gynecology and Obstetrics
Women’s Health Johns Hopkins Hospital
University of Minnesota Baltimore, Maryland
Minneapolis, Minnesota
Stephanie L. Wethington, MD,
Orlene Thomas, MD MSc
Assistant Professor Assistant Professor, Gynecology Oncology
Julia Timofeev, MD MaryAnn Wilbur, MD, MPH, MHS

Assistant Professor Instructor
Division of Maternal Fetal Medicine Department of Obstetrics and Gynecology
Department of Gynecology and Obstetrics Harvard Medical School
Johns Hopkins University School of Medicine Boston, Massachusetts
Baltimore, Maryland
Tenisha Wilson, MD, PhD
Connie L. Trimble, MD Resident Physician
Professor Department of Gynecology and Obstetrics
Departments of Gynecology and Obstetrics, Johns Hopkins University School of Medicine
Oncology, and Pathology Baltimore, Maryland
Baltimore, Maryland Harold Wu, MD
Clinical Fellow, Minimally Invasive
Sandy R. Truong, MD Gynecology
Baltimore, Maryland
Camilla Yu, MD
Katelyn A. Uribe, MD Resident Physician
Baltimore, Maryland
Howard A. Zacur, MD, PhD
Arthur Jason Vaught, MD Theodore and Ingrid Baramki Professor of
Assistant Professor Reproductive Endocrinology
Department of Gynecology and Obstetrics Fellowship Director for Reproductive
Johns Hopkins University School of Medicine Endocrinology and Infertility
Baltimore, Maryland Division of Reproductive Endocrinology and
Infertility
Baltimore, MarylandSixth Edition
Contents
Dedication vii
Preface ix
Contributors xi
Part I: Obstetrics 1
1 Prepregnancy Counseling and Prenatal Care 1
Marlena Simpson Halstead and Rachel Chan Seay
2 Normal Labor and Delivery, Operative Delivery,

and Malpresentations 15
Samantha de los Reyes and Orlene Thomas
3 Complications of Labor and Delivery 33

Benjamin K. Kogutt and Clark T. Johnson
4 Fetal Assessment 45
Nicole R. Gavin and Ahmet Baschat
5 Prenatal Complications 55
Jerome J. Federspiel and Jeanne S. Sheffield
6 Preterm Labor and Preterm Prelabor Rupture of Membranes 65

Kristin Darwin and Clark T. Johnson
7 Third-Trimester Bleeding 78
Isa Ryan and Shari M. Lawson
8 Perinatal Infections 87
Edward K. Kim and Jeanne S. Sheffield
9 Congenital Anomalies 109

Juliet C. Bishop and Angie C. Jelin
10 Multifetal Gestation 123

Sunitha Suresh and Julia Timofeev
11 Endocrine Disorders of Pregnancy 130

Tenisha Wilson and Svena D. Julien
12 Hypertensive Disorders of Pregnancy 154

Arthur Jason Vaught and Braxton Forde
13 Cardiopulmonary Disorders of Pregnancy 166

Reneé Franklin Moss and Ernest M. Graham
14 Genitourinary Assessment and Renal Disease in Pregnancy 183

Lauren M. Kucirka and Cynthia H. Argani
15 Gastrointestinal Disease in Pregnancy 190

Steve C. Amaefuna and Abimbola Aina-Mumuney
16 Autoimmune Disease in Pregnancy 197

Elizabeth Oler and Donna Maria Neale
xix
xx CONTENTS
17 Neurologic Diseases in Pregnancy 210

Ana M. Angarita and Irina Burd
18 Psychiatric Disorders in the Pregnant and Postpartum Patient 221

Jaden R. Kohn and Lauren M. Osborne
19 Substance Use Disorders in Pregnancy 237

Marielle S. Gross and Lorraine A. Milio
20 Hematologic Disorders of Pregnancy 254

Christopher M. Novak and Rita W. Driggers
21 Neoplastic Diseases in Pregnancy 281

Meghan McMahon and Jessica L. Bienstock
22 Skin Conditions in Pregnancy 294

Angela K. Shaddeau and Crystal Aguh
23 Surgical Disease and Trauma in Pregnancy 298

Bernard D. Morris III and Nancy A. Hueppchen
24 Postpartum Care and Breastfeeding 308

Timothee Fruhauf and Silka Patel
25 Obstetric Anesthesia 319

Kristen Ann Lee and Jamie Murphy
Part II: General Gynecology 329

26 Primary and Preventive Care 329
Sandy R. Truong and Tochi Ibekwe
27 Infections of the Genital Tract 346

Amanda C. Mahle and Jenell S. Coleman
28 Contraception and Sterilization 373

Stacy Sun and Jennifer A. Robinson
29 Abortion 386
Jessica K. Lee and Chavi Kahn
30 First and Second Trimester Pregnancy Loss and

Ectopic Pregnancy 391
Jill Edwardson and Carolyn Sufrin
31 Abnormal Uterine Bleeding 402

Katerina Hoyt and Jean R. Anderson
32 Chronic Pelvic Pain 416

Melissa Pritchard McHale and Khara M. Simpson
33 Uterine Leiomyomas and Benign Adnexal Masses 434

Esther S. Han and Mostafa A. Borahay
CONTENTS xxi
34 Breast Diseases 446

Harold Wu and Shriddha Nayak
35 Benign Vulvar Disorders 461

Megan E. Lander and Cybill R. Esguerra
36 Female Sexual Function and Dysfunction 469

Yangshu Linda Pan and Linda C. Rogers
37 Intimate Partner and Sexual Violence 478

Morgan Mandigo and Orlene Thomas
38 Pediatric Gynecology 487

Malorie Snider and Carla Bossano
Part III: Reproductive Endocrinology

and Infertility 503
39 The Menstrual Cycle 503
Brittany L. Schuh and Chailee Faythe Moss
40 Infertility and Assisted Reproductive Technologies 507

Christina N. Cordeiro Mitchell and Mindy S. Christianson
41 Recurrent Pregnancy Loss 526

Kamaria C. Cayton Vaught and Mindy S. Christianson
42 Menstrual Disorders: Endometriosis, Dysmenorrhea, and

Premenstrual Dysphoric Disorder 534
Camilla Yu and Jensara Clay
43 Evaluation of Amenorrhea 544

Victoire Ndong and Chantel I. Cross
44 Polycystic Ovary Syndrome and Hyperandrogenism 556

Jacqueline Y. Maher, Maria Facadio Antero, and Howard A. Zacur
45 Definitions and Epidemiology of Menopause 570

Jacqueline Y. Maher and Wen Shen
Part IV: F emale Pelvic Medicine and

Reconstructive Surgery 581
46 Urinary Incontinence and Lower Urinary Tract Symptoms 581
Prerna Raj Pandya and Chi Chiung Grace Chen
47 Pelvic Organ Prolapse 589

David A. Lovejoy and Chi Chiung Grace Chen
48 Anal Incontinence 598

Emily Myer and Tola Fashokun
xxii CONTENTS
Part V: Gynecologic Oncology 603

49 Cervical Intraepithelial Neoplasia 603
Anna L. Beavis and Connie L. Trimble
50 Cervical Cancer 615

Melissa Pritchard McHale and Kimberly Levinson
51 Cancer of the Uterine Corpus 633

Marla Scott and Amanda Nickles Fader
52 Ovarian Cancer 648

Lea A. Moukarzel and Edward J. Tanner III
53 Hereditary Cancer Syndromes 667

Anja Frost and Deborah K. Armstrong
54 Premalignant and Malignant Disease of the Vulva and Vagina 678

Megan E. Gornet and Rebecca Stone
55 Gestational Trophoblastic Disease 688

Danielle B. Chau and Kimberly Levinson
56 Chemotherapy, Antineoplastic Therapy, and Radiation Therapy 701

Tiffany Nicole Jones and Stéphanie Gaillard
57 Palliative and End-of-Life Care 714

Melissa H. Lippitt and Stephanie L. Wethington
Part VI: Surgery in Obstetrics and Gynecology 727

58 Anatomy of the Female Pelvis 727
Katherine F. Chaves and Jean R. Anderson
59 Surgical Approaches in Gynecologic Surgery 740

MaryAnn Wilbur and Kristin Patzkowsky
60 Perioperative Care and Complications of Gynecologic Surgery 749

Katelyn A. Uribe and Karen C. Wang
61 Critical Care 767

Lauren Thomaier and Arthur Jason Vaught
62 Quality, Safety, and Value in Women’s Health 792

Anna Jo Smith and Judy M. Lee
Index 797
I Obstetrics
Prepregnancy
1 Counseling and
Prenatal Care
Marlena Simpson Halstead and Rachel Chan Seay
PREPREGNANCY CARE AND COUNSELING

• Prepregnancy care is an important time during the women’s health continuum
that can reduce maternal-fetal morbidity and mortality. It is an opportunity prior
to conception to optimize health, identify and modify risk factors, and provide ed-
ucation about considerations and behaviors that could affect a future pregnancy.
Preconception counseling is becoming ever more important as more women
are diagnosed with chronic conditions such as hypertension, diabetes mellitus,
obesity, autoimmune diseases, and psychiatric illness. Preconception counseling
should be implemented into the routine medical care of all reproductive-aged
women. Any encounter with nonpregnant women with reproductive potential
is an opportunity to improve reproductive health and impact future obstetric
outcomes.
• A thorough review of medical, surgical, psychiatric, gynecologic, and obstetric
health can expose potential complications in a planned pregnancy or factors con-
tributing to infertility.
• A full obstetric history should be taken during prepregnancy care and reviewed
at the initial prenatal visit. Family planning and pregnancy spacing needs should
be discussed, and women should be advised about the risks of interpregnancy
intervals shorter than 6 months. Prior pregnancy complications should be dis-
cussed as well as the risk of recurrence and possible interventions that might
decrease that risk.
• Prepregnancy care should include a review of age-appropriate cancer screening.
If there is a history of inconsistent or outdated testing, this evaluation should be
completed. Discussion about appropriate pregnancy timing should be considered
to avoid delayed cancer diagnosis or treatment.
• Consultation with maternal-fetal medicine or reproductive endocrinology and
infertility may be considered in women with a history of poor obstetric outcomes
or chronic medical conditions.
1
2 OBSTETRICS
Health Optimization and Medical Assessment

Approximately half of pregnancies are unintended or unplanned, so it is important
to counsel all women with reproductive potential about wellness and healthy habits.
In turn, a large portion of women consciously attempt pregnancy and actively seek
counseling about health optimization, management of chronic illness, risk identifica-
tion, and behavior modification prior to conception.
• Preconception care should include a thorough assessment of an individual’s med-
ical problems and risk assessment (Table 1-1). Many chronic medical conditions
have implications for fertility and pregnancy, and the goal of prepregnancy care is
to identify and optimally manage these conditions prior to pregnancy. Referral to
specialists, including maternal-fetal medicine, may be appropriate, both for health
optimization and for discussion of potential effects of a pregnancy on the chronic
medical condition. While there are many medical conditions that should be opti-
mized before conception, we discuss three common conditions here:
• Diabetes mellitus. See chapter 11. Preconception counseling should include a
review of current management in women with a prior diagnosis or a review of
risk factors and recommendations to obtain diagnostic testing when applicable.
Poorly controlled diabetes is associated with a risk of major fetal malformations.
Pregestational diabetes mellitus is also associated with spontaneous abortion,
preterm birth, and accelerated or excessive fetal growth.
• Chronic hypertension. See chapter 12. The assessment of chronic hyperten-
sion should include the duration of illness, current medication regimen, and its
Table 1-1 Preconception Risk Assessment: Laboratory Testinga
Recommended Screening for

Recommended for All Women Some Women
Hemoglobin level or hematocrit Tuberculosis
Rh factor Hepatitis C
Offer genetic screening for cystic Gonorrhea and chlamydia
fibrosis, spinal muscular atrophy. HIV
Urine dipstick Syphilis
Age-appropriate cervical cancer Varicella IgG
screening (Pap smear ⫾ HPV Toxoplasmosis IgG
co-testing) CMV IgG
Hepatitis B surface antigen Parvovirus B19 IgG
Rubella IgG Consider genetic carrier screening
Illicit drug screen for hemoglobinopathies, Tay-Sachs
disease, Canavan disease, or other
genetic diseases.
Lead level
Abbreviations: CMV, cytomegalovirus; HIV, human immunodeficiency virus; HPV, human papilloma-
virus; IgG, immunoglobulin G.
a
Adapted from U.S. Department of Health and Human Services. Caring for Our Future: The Content
of Prenatal Care. A Report of the Public Health Service Expert Panel. Washington, DC: U.S. Depart-
ment of Health and Human Services; 1989.
Prepregnancy Counseling and Prenatal Care • Prepregnancy Care and Counseling 3
degree of successful control. Further investigation into secondary causes of hy-
pertension and other systemic sequelae may be needed, such as an assessment of
baseline renal function or testing for ventricular hypertrophy. Recommendations
should be made to alter current medication regimens to avoid angiotensin-con-
verting enzyme inhibitors and angiotensin receptor blockers, as these agents are
contraindicated in pregnancy. Preconception counseling should include a discus-
sion about the risk of adverse outcomes during the pregnancy, including super-
imposed heart failure, stroke, worsening underlying renal disease, preeclampsia,
placental abruption, fetal growth restriction, and preterm delivery.
• Obesity. The incidence of obesity in reproductive-aged women is increasing.
Obesity is associated with problems including but not limited to infertility, re-
current pregnancy loss, preterm delivery, pregnancy-induced hypertension, ges-
tational diabetes, stillbirth, and higher rates of cesarean delivery.
¢ Optimal control and management obesity ideally occurs prior to conception.
Improvement in medical comorbidities has been demonstrated in women

with even modest weight loss prior to pregnancy. This weight loss can be
achieved by medical or surgical means. Medications used for weight loss are
not recommended during conception or pregnancy. Motivational interview-
ing to support healthy diet and physical activity has been used within the
clinical setting to promote weight loss in this population.
¢ The number of bariatric surgical procedures performed annually is increasing,
and the majority of these patients are reproductive-aged females. Higher fer-
tility rates are seen following surgery as a result of the rapid weight loss and
restoration of predictable ovulation. Women should be counseled regarding
contraceptive options with the recommendation to avoid pregnancy for 12 to
24 months following bariatric surgery.
Substance Use Assessment

All patients should routinely be asked about their use of nicotine products, alcohol, and
prescription as well as illicit substances. The preconception interview allows timely ed-
ucation about drug use and effects on pregnancy, informed decision making about the
risks of using these substances at the time of conception and throughout pregnancy,
and the introduction of interventions for women who need treatment (see chapter 19).
• Nicotine products. Tobacco use remains the single largest preventable cause of
disease and premature death in the United States. Screening for tobacco use and
providing cessation counseling are some of the most effective preventive health
actions provided by health care providers.
• Tobacco use can negatively impact fertility and a future pregnancy by increas-
ing rates of miscarriage, ectopic pregnancy, preterm birth, placental abruption,
intrauterine growth restriction, low infant birth weight, and perinatal mortality.
Tobacco exposure can continue to negatively impact the neonate, as children of
smokers have increased risk of asthma, infantile colic, and childhood obesity.
• Tobacco cessation should be recommended prior to conception and readdressed
throughout the pregnancy and postpartum period. Nicotine replacement therapy
with either gum or transdermal patch can be considered for women attempt-
ing to stop smoking. These forms of replacement reduce fetal exposure to toxic
chemicals like carbon monoxide. In general, emphasis on offering techniques
to stop smoking rather than mandating cessation alone has been found to be a
more successful strategy in counseling cessation.
4 OBSTETRICS
• Alcohol. Alcohol is a well-established teratogen. There is no known safe amount

of alcohol use during pregnancy or while trying to get pregnant. Ethanol freely
traverses the maternal-fetal placental barrier and the fetal blood-brain barrier. Al-
though the threshold for adverse events is not currently known, a dose-related rela-
tionship between alcohol and the consequences in pregnancy has been established.
The US Surgeon General advises woman who are pregnant or planning pregnancy
to abstain from drinking alcohol.
• Fetal alcohol spectrum disorder refers to a range of effects that can occur when a
fetus is exposed to alcohol during pregnancy, including disturbances in intellect,
learning abilities, behavior, growth, vision, and hearing. Alcohol can alter cardiac
development, presenting as atrial or ventricular septal defects or conotruncal
heart defects. Children born to women who abuse alcohol are at higher risk
for skeletal, renal, and ocular defects than those not exposed to alcohol during
pregnancy. Fetal alcohol syndrome represents the most severe form of the fetal al-
cohol spectrum disorder and is characterized by neurodevelopmental and central
nervous system disturbances, growth deficiencies, and characteristic abnormal
facial features. This group of conditions is preventable.
• All women should be screened annually for alcohol dependence and abuse, and
all pregnant women should be screened as early as possible in pregnancy. Ameri-
can College of Obstetricians and Gynecologists (ACOG) recommends the use of
short validated screening tools, such as the T-ACE tool (Table 1-2). Identifying
at-risk behavior allows for early intervention and timely referral for treatment.
• Marijuana. Marijuana is the most commonly used illicit substance during preg-
nancy, and marijuana use is increasing with marijuana legalization. The receptor
on which marijuana acts has been found in the central nervous system of fetuses
as early as 14 weeks’ gestation. Animal models have suggested that tetrahydrocan-
nabinol is able to cross the placenta, and there is some evidence in human research
that it is also present in breast milk. Emerging evidence suggests that prenatal
exposure to marijuana may result in impaired cognition and possibly an increased
susceptibility to other illicit or abused substances. Marijuana use in pregnancy
may be associated with an increased risk of stillbirth, preterm delivery, and lower
birth weights. In addition to potential physiologic effects, patients should also be
informed of the potential ramifications of a positive toxicology screen result in
pregnancy.
Table 1-2 T-ACE Screening Tool for Alcohol Misusea
Tolerance How many drinks does it take to make you feel high?
Annoyed Have people annoyed you by criticizing your drinking?
Cut down Have you ever felt you ought to cut down on your drinking?
Eye-opener Have you ever had a drink first thing in the morning to steady
your nerves or get rid of a hangover?
a
Positive score is 2 or more points. Two points are assigned if more than two drinks for the Tolerance
question. One point is assigned if person responds “yes” to the Annoyed, Cut down, or Eye-opener
question.
• Opioids. The prevalence of opioid use in pregnancy has increased dramatically in
recent years. Opioid use disorder is a chronic disease that can be managed success-
fully when identified. Several validated screening tools exist, and ACOG recom-
mends early universal screening in pregnancy for opioid use disorder.
• Opioids can be ingested orally, intravenously, or by inhalation. They can be swal-
lowed, chewed, or placed as suppositories. All opioid substances may result in
overdose, causing respiratory depression or death. Additionally, injected opioids
carry the risk of blood-borne diseases such as human immunodeficiency virus
(HIV) and hepatitis, and additional vaccination and testing should be consid-
ered. Opioid use disorder is also associated with concomitant psychiatric disor-
ders such as depression, anxiety, and posttraumatic stress disorder. Thus, mental
health screening is particularly important in these patients.
• The literature is inconsistent regarding the risk of congenital anomalies follow-
ing prenatal opioid exposure. Chronic use during pregnancy is associated with
an increased risk of fetal growth restriction, preterm birth, stillbirth, and placen-
tal abruption. Neonatal abstinence syndrome is the drug withdrawal pattern that
may develop in neonates exposed to chronic maternal opioid use in utero. It may
last days to weeks and is characterized by poor feeding, poor sleep, hypertonicity,
sneezing, high-pitched cry, diarrhea, tremors, or seizure.
• Cocaine. Many of the adverse effects of cocaine are related to vasoconstriction
or hypertensive events. Cocaine use is associated with cardiac ischemia, cerebral
infarction or hemorrhage, and malignant hypertension and may lead to sudden
cardiac death. Cocaine use in pregnancy is associated with spontaneous abortion,
stillbirth, placental abruption, preterm labor, preterm rupture of membranes, and
fetal growth restriction. Fetuses exposed to cocaine in utero have an increased risk
of behavioral abnormalities, cognitive impairment, and impaired motor function.
• Amphetamine. Data are limited when looking specifically at methamphetamine
use in pregnancy. Women who use methamphetamine frequently use other illicit
drugs as well which can confound outcomes. As trends demonstrate an increase in
use within the United States, it is important to be aware of this compound and its
effects. Methamphetamine can be ingested orally, intravenously, or rectally as well
as by inhalation or nasal insufflation. Intrauterine exposure has been consistently
associated with infants who are small for gestational age and may increase the risk
of early childhood neurodevelopmental abnormalities. At present, teratogenicity
has not been demonstrated.
Psychiatric Health
Psychiatric illness during pregnancy is associated with a higher risk of postpartum psy-
chiatric illness, less or inconsistent prenatal care, and poor maternal and infant out-
comes. In addition, antidepressants and antipsychotic medications have been associated
with decreased ovulation and infertility. Evaluation for psychiatric illness and optimi-
zation of a medical regimen should be encouraged prior to pregnancy (see chapter 18).
Review of Medications
All prescription medications, over-the-counter drugs, and dietary supplements should
be reviewed. Male partners should also be screened for the use of androgens, which
is associated with male factor infertility. If attempting pregnancy, it is important to
review the safety of all current medications prior to conception. Secondary to the
6 OBSTETRICS
oversimplification of safety profiles, the historic categories for medications in preg-

nancy have been replaced with descriptions that are felt to be more comprehensive.
Assistance in answering questions about reproductive toxicology is available through
the online database REPROTOX (http://www.reprotox.org). Potentially teratogenic
medications should be adjusted in collaboration with the prescribing health care
providers. Both the maternal and fetal risk of continuing or discontinuing medica-
tion should be considered. In some cases, discontinuation of a medication may be
associated with a greater risk for maternal well-being when compared to potential
medication-related risks to the fetus.
Infectious Disease Screening
It is important to clarify a history of infectious diseases and assess past and current risk
of exposure and need for screening. A woman should be screened based on age and
risk factors for gonorrhea, chlamydia, syphilis, HIV, hepatitis, tuberculosis, toxoplas-
mosis, and Zika virus as appropriate. A history of herpes simplex virus, particularly
genital involvement, should be assessed. Listeria infection is associated with obstetric
and neonatal complications, and dietary recommendations should be reviewed.
Immunizations
Both prepregnancy and prenatal counseling should include a review of immunization
status and recommendations for appropriate vaccination.
• Influenza. This vaccine is recommended annually during the flu season for all pregnant
women regardless of gestational age. Patients with conditions that make them more
susceptible to the illness, such as cardiopulmonary disorders, immunosuppression, and
diabetes mellitus, should be especially urged to comply with this recommendation.
• Tetanus, diphtheria, and pertussis. The Centers for Disease Control and Pre-
vention recommends administering the tetanus, diphtheria, and pertussis vaccine
during each pregnancy between 27 and 36 weeks, preferably during the earlier part
of this time period.
• Hepatitis B. Administration of the hepatitis B virus (HBV) vaccine or hepatitis B
immune globulin is safe in pregnancy. Women at high risk for HBV who should
receive the vaccine during pregnancy include those with a history of intravenous
drug use, those at risk from sexual exposure (multiple sex partners, partners of hep-
atitis B surface antigen–positive persons, receiving treatment for another sexually
transmitted disease) or occupational exposure, those who reside in places where
adults have high risk for hepatitis B infection (dialysis unit, nursing institutions),
and those who are recipients of clotting factor concentrates.
• Pneumococcal vaccine. This vaccine is indicated for pregnant women at high risk
for this infection, such as women with heart disease, HIV infection, lung disease,
sickle cell disease, and diabetes.
• Live vaccines should be administered either prior to or after pregnancy.
• The measles, mumps, and rubella vaccine contains live attenuated antigens. This
vaccine should be administered outside of pregnancy and optimally more than
4 weeks prior to conception.
• The varicella vaccine is a live attenuated vaccine and should be administered
outside of pregnancy to those without a clinical history of the chicken pox or
verified immunity.
• The human papillomavirus vaccination is not currently recommended during
pregnancy.
Social Assessment
• Violence, intimate partner violence, and reproductive coercion. Women of all ages
may experience violence, but those of reproductive age are at highest risk. Screening
for violence and intimate partner violence is a core part of women’s preventive health
and should routinely be included in prepregnancy and prenatal care. In addition
to maternal trauma, physical abuse during pregnancy has been associated with fetal
injury, stillbirth, antepartum hemorrhage, placental abruption, and preterm labor.
All patients should be screened early and often, and patients should be made aware
that all patients are screened. Legal and community resources should be provided to
women who disclose abuse or reproductive coercion (see chapter 37).
• Housing and food security. Patients should be asked about social support and
screened for housing and food security. Referral to social work and appropriate
assistance programs should be incorporated into care as needed.
• Insurance coverage and financial difficulties. Many women do not know the
eligibility requirements or extent of maternity coverage provided by their insurance
carrier or may lack medical insurance coverage altogether. Referral for medical as-
sistance programs should be part of preconception planning as needed.
Family History
• The preconception evaluation should include a thorough family history of the
patient and her partner, including genetic disorders; congenital or chromosomal
anomalies; mental disorders; consanguinity; and breast, ovarian, uterine, and colon
cancer. Ethnic background of a couple may help guide recommendations for carrier
screening. Referral to a genetics counselor may be considered.
• Early identification of carrier status can help guide reproductive goals and plans for
attempting pregnancy; performing testing before, during, and after pregnancy; or
using assistive technologies to achieve pregnancy.
Maternal Age
• Women who will be 35 years or older at the time of delivery are considered to be of
advanced maternal age and are at increased risk for fetal aneuploidy, infertility, stillbirth,
and other pregnancy-associated diseases such as hypertension and diabetes. Patients
should be counseled on their options for aneuploidy screening and diagnostic testing.
Nutritional Assessment
• Folic acid. All women of reproductive age should take folic acid supplementation.
Adequate folic acid intake decreases the risk for defects related to complete closure of
the neural tube (NTDs). Average-risk women should consume 400 ␮g daily. Most
prenatal multivitamins contain sufficient folic acid for average-risk women. Women
who take antiepileptic medications or have had a prior pregnancy affected by an
NTD are at higher risk and should consume higher levels (4 mg daily) of folic acid.
• Excessive use of supplements containing vitamin A should be avoided. At dosages
of more than 20,000 IU daily, vitamin A carries a risk of teratogenic effects.
• Eating habits and disorders. Patterns in eating (eg, fasting, caloric restriction, use
of nutritional supplements) should be discussed. Women at risk of eating disorders
should be counseled, and multimodal treatment teams should ideally be established
prior to pregnancy and include a nutritionist and a mental health provider.
8 OBSTETRICS
R O U T I N E P R E N ATA L C A R E
Prenatal care is an ongoing process of health optimization for the woman and her
fetus and requires continual assessment of medical and social determinants of health.
Prenatal care is associated with improved reproductive outcomes including decreases
in preterm birth, fetal growth restriction, and neonatal death. See Table 1-3 for
recommendations for routine prenatal tests.
Pregnancy Dating
It is important to establish the correct gestational dating of a pregnancy as soon as
possible during prenatal care. This can influence interpretation of antenatal testing
and determine optimal delivery timing. Assuming that ovulation and conception oc-
curred on the 14th day of a 28-day cycle, the average length of a human pregnancy
is 280 days, counting from the first day of the last menstrual period (LMP). As soon
Table 1-3 Routine Prenatal Care
Timing Exams and Tests

Initial obstetric visit History and physical exam
Blood/Rh type, antibody screen, CBC, rubella, Hgb
electrophoresis (if at risk for hemoglobinopathy),
urine culture, urine toxicologya
Infection screening for syphilisa, HBV, HIVa, chlamydia,
and gonorrhea. Consider HCV screening in
pregnancy women at increased risk.
Cervical cancer screening as needed
Sonogram to confirm gestational age, viability, and
number of fetuses
Offer genetic testing for CF, SMA, or other carrier
screening tests based on personal or family history.
11-14 wk gestation Aneuploidy screening option: first trimester screen
16-20 wk gestation Offer MSAFP.
Aneuploidy screening option: quadruple (“quad”)
screen
18-22 wk gestation Ultrasound evaluation of fetal anatomy and placental
location
24-28 wk gestation Blood/Rh type, antibody screen, CBC, GDM screening
Infection screening: syphilisa, HIVa
36 wk gestation Group B streptococcus rectovaginal culture
Consider repeat screening for gonorrhea/chlamydia.
Verify fetal presentation.
Abbreviations: CBC, complete blood count; CF, cystic fibrosis; GDM, gestational diabetes mellitus;
HBV, hepatitis B virus, HCV, hepatitis C virus; Hgb, hemoglobin; HIV, human immunodeficiency virus;
MSAFP, maternal serum ␣-fetoprotein; SMA, spinal muscular atrophy.
a
State-mandated testing may vary by location.
Prepregnancy Counseling and Prenatal Care • Routine Prenatal Care 9
Table 1-4 Accuracy of Pregnancy Dating by Ultrasonography

According to Gestational Agea
Gestational Age (wk) Ultrasonographic Measurements Accuracy

⬍8 6/7 CRL ⫾5 d
9–13 6/7 CRL ⫾7 d
14–15 6/7 BPD, HC, FL, AC ⫾7 d
16–21 6/7 BPD, HC, FL, AC ⫾10 d
22–27 6/7 BPD, HC, FL, AC ⫾14 d
⬎28 BPD, HC, FL, AC ⫾21 d
Abbreviations: AC, abdominal circumference; BPD, biparietal diameter; CRL, crown-rump length;
FL, femur length; HC, head circumference.
a
Adapted with permission from American College of Obstetricians and Gynecologists Committee on
Obstetric Practice. ACOG Committee Opinion No. 700: methods for estimating the due date. Obstet
Gynecol. 2017;129(5):e150-e154. (Reaffirmed 2019). Copyright © 2017 by The American College
of Obstetricians and Gynecologists.
as data from the LMP and first ultrasound are obtained, an estimated date of delivery
(EDD) should be established and clearly communicated with the patient.
• Pregnancies resulting from assisted reproductive technology should use the assisted
reproductive technology–guided gestational age for establishing the EDD.
• Naegele’s rule. To estimate the date of delivery, determine the first day of the
LMP, add 7 days, then add 1 year, and then subtract 3 months.
• Ultrasonographic dating. If EDD by ultrasound measurements falls within the
range of accuracy, the LMP is used to establish the EDD as confirmed by ultra-
sound (Table 1-4).
Nutrition, Weight Gain, and Exercise

• Nutrition. A pregnant woman requires approximately 15% more calories than she
does when not pregnant, that is, typically an additional 300 to 500 kcal/d.
• Iron. Consumption of iron-rich foods is encouraged throughout pregnancy. The
National Academy of Sciences recommends adding 27-mg iron supplementation
(typically present in prenatal vitamins) to the average diet. Additional supple-
mentation may be required.
• Weight gain. Recommendations regarding total weight gain in pregnancy aim
to optimize maternal and fetal outcomes. These recommendations are based on
prepregnancy body mass index (BMI) and were established by the Institute of
Medicine (Table 1-5).
• Obesity (BMI ⬎ 30 kg/m2) is associated with an increased risk for poor pregnancy
outcomes including miscarriage, stillbirth, fetal anomalies, preterm delivery, gesta-
tional diabetes and hypertension, preeclampsia, thromboembolic event, cesarean de-
livery, and shoulder dystocia. Women with a history of gastric bypass surgery should
be evaluated for nutritional deficiencies (eg, protein, iron, vitamin B12, folate, vitamin
D, calcium). Weight loss counseling and referral to a nutritionist should be offered.
• Physical exercise. The US Department of Health and Human Services recommends
that women participate in at least 150 minutes of moderate physical activity per week
10 OBSTETRICS
Table 1-5 Recommended Range of Total Weight Gain in Pregnancy
Prepregnancy
Prepregnancy Body Mass
Weight Category Index (kg/m2) Singleton Twin Gestation
Underweight ⬍18.5 28-40 lb No recommendation
Normal weight 18.5-24.9 25-35 lb 37-54 lb
Overweight 25-29.9 15-25 lb 31-50 lb
Obese (all classes) 30 and greater 11-20 lb 25-42 lb
during pregnancy and the postpartum period. This should be continued as tolerated
during the pregnancy. Absolute contraindications to aerobic exercise during preg-
nancy include severe cardiac or pulmonary disease, cervical insufficiency or cerclage,
multiple gestation at risk of premature labor, persistent second- or third-trimester
bleeding, placenta previa, ruptured membranes, pregnancy-induced hypertension,
and severe anemia. Relative contraindications to aerobic exercise during pregnancy
include poor health status prior to pregnancy, anemia, unevaluated maternal cardiac
arrhythmia, lung disease, poorly controlled type 1 diabetes, extremes of maternal
weight, orthopedic or neurologic limitations, poorly controlled thyroid disease, and
fetal growth abnormalities. Contact sports and activities with increased risk of falling
or involving extremes in temperature should be avoided.
Immunizations
• See “Immunizations” under “Prepregnancy Care and Counseling” section.
Genetic Screening
• All pregnant women should be offered testing to assess risk of fetal aneuploidy.
Fetal aneuploidy refers to conditions associated with an abnormal number of
chromosomes. Whereas chromosomal abnormalities occur in approximately 1 in
150 live births, the prevalence is greater as aneuploidy accounts for a large pro-
portion of early pregnancy loss.
• Risk factors to consider for referral to genetic counseling (Table 1-6) include family
history, maternal age, ethnicity, drug and environmental exposures, and obstetric
and medical history.
• Providing access to prenatal genetic counseling and screening allows providers to
provide adequate prenatal interventions if needed, optimize neonatal outcomes by
organizing appropriate resources following delivery, and provide relative reassur-
ance to parents when testing is normal.
• ACOG recommends providing universal carrier screening for cystic fibrosis
and spinal muscular atrophy to women who are considering pregnancy or are
currently pregnant. Case-specific carrier screening can be offered for Tay-Sachs
disease, fragile X syndrome, and certain hemoglobinopathies.
• Down syndrome (trisomy 21) is the most common condition associated with
an abnormal chromosome number found in live born children that is not related
Table 1-6 Reasons to Consider Referral for Genetic Counseling
Mother age 35 or older at estimated date of delivery

Fetal anomalies detected via ultrasonography
Abnormal first trimester serum/nuchal translucency screening
Abnormal triple/quad screening or abnormal ␣-fetoprotein test results
Parental exposure to teratogens (includes certain drugs, radiation)
Family history of genetic disease (includes chromosome, single gene, and
multifactorial disorders)
Personal or family history of birth defects or mental retardation
Certain parental medical conditions (eg, cancer, congenital heart disease)
Membership in ethnic group in which certain genetic disorders are frequent
when appropriate screening for or prenatal diagnosis of the disease is
available (eg, sickle cell anemia, Tay-Sachs disease, Canavan disease,
thalassemia)
Consanguinity
Infertility
Recurrent pregnancy loss
Stillbirth or neonatal death
Infant, child, or adult with dysmorphic features, developmental and/or growth
delay, ambiguous genitalia, or abnormal sexual development
to a sex chromosome disorder. All cases are identified by the presence of an extra
chromosome 21, which can result from nondisjunction, translocations, or mosa-
icism. Down syndrome can vary in presentation and is associated with hypotonia,
characteristic facial features, congenital heart defects, intellectual disability, and
intestinal atresia (see chapter 9).
• Patau syndrome (trisomy 13) and Edward syndrome (trisomy 18) are more
severe disorders associated with multiorgan birth defects and intellectual disability.
The majority of cases die in utero or within the first year of life.
Screening Tests
See Table 1-7 for a summary of the common prenatal genetic screening tests.
First Trimester Screening
• First trimester screening is performed between 10 0/7 weeks’ and 13 6/7 weeks’
gestation. The test includes nuchal translucency, maternal age, and two maternal
serum markers: free ␤-human chorionic gonadotrophin (hCG) and pregnancy-
associated plasma protein-A.
• Factors required for accurate risk calculation include a history of prior birth with
aneuploidy, race, number of fetuses, and current maternal weight.
• The detection rate for trisomy 21 is approximately 82% to 87% with a 5% false-
positive rate, which is improved by adding an ultrasound assessment of the fetal
nasal bone (about 95%). Detection rate for trisomy 18 is about 95%.
• First trimester screening does not include assessment of risk for NTDs.
12 OBSTETRICS
Table 1-7 Summary of Prenatal Genetic Screening Testsa
Testing Detection
Time Rate for
Test Components Frame Comments Trisomy 21
First trimester Maternal age 10-13 Provides risk for 82%-87%
screen Maternal serum: 6/7 wk trisomy 21 and 95% (including
• hCG 13/18; improved nasal bone
• PAPP-A detection when assessment)
Fetal ultrasound: fetal nasal bone
• Nuchal is assessed
translucency
• ⫾ Nasal bone
Quad screen Maternal serum: 15-22 Provides risk for 81%
• hCG 6/7 wk trisomy 21,
• MSAFP 18, and open
• uE3 NTDs
• DIA
Combined Fetal nuchal First and Detection rate 94%-96%
screening translucency second for trisomy 21
(integrated) Maternal serum: trimester equivalent to
• PAPP-A (as noted first trimester
• hCG above) screen when
• MSAFP nasal bone is
• uE3 included
• DIA
Combined Patient given First and Allows patients 95%
screening results of second to decide the
(sequential) first trimester trimester extent of testing
screen and (as noted they wish to
then decide above) pursue
whether to
undergo
invasive testing
(if positive) or
quad screen
(if negative).
MSAFP MSAFP Second Provides risk for NA
trimester open NTDs
Cell-free Maternal blood 10 wk and Only recommended ⬎98%
fetal DNA draw with later for patients at
analysis analysis of higher risk of
fetal DNA aneuploidy
Abbreviations: ␤-hCG, ␤-human chorionic gonadotropin; DIA, dimeric inhibin A; MSAFP, maternal
serum ␣-fetoprotein; NTDs, neural tube defects; PAPP-A, pregnancy-associated plasma protein-A;
uE3, unconjugated estriol.
a
Data from American College of Obstetricians and Gynecologists Committee on Practice Bulletins—
Obstetrics, Committee on Genetics, Society for Maternal-Fetal Medicine. ACOG Practice Bulletin
No. 163: screening for fetal aneuploidy. Obstet Gynecol. 2016;127:e123-e137.
Second Trimester Screening
• The quad screen is typically performed between 15 0/7 weeks’ and 22 6/7 weeks’
gestation and can establish risk for trisomy 18 and 21 and NTDs.
• Four maternal serum markers are evaluated: hCG, maternal serum ␣-fetoprotein
(MSAFP), unconjugated estriol (uE3), and dimeric inhibin A (DIA). Maternal age
is also noted during the evaluation.
• Trisomy 21 is detected at a rate of 75% for women younger than 35 years and 90%
for those older than 35 years.
• Elevated ␣-fetoprotein is associated with defects of the abdominal wall or NTDs.
Combined Screening
• Combined screening uses combined first and second trimester screening to adjust
a woman’s age-related risk for fetal aneuploidy.
• Integrated screening uses nuchal translucency and pregnancy-associated plasma
protein-A from the first trimester screening as well as hCG, MSAFP, uE3, and DIA
from the second trimester screening. Results are reported only after both screening
tests are completed. The detection rate for this method is 94% to 96% with 5%
false positives; this is equivalent to first trimester screening when nasal bone is
included in the risk assessment.
• Sequential screening involves giving the patient the first trimester screen results. If
at high risk, patients are given the option for invasive testing, whereas those at low
risk can still undergo second trimester screening to achieve a higher detection rate.
Cell-Free Fetal DNA Screening
• Fragments of fetal DNA can be isolated from maternal blood to determine the risk
for several fetal conditions. This test can be performed between 10 weeks’ gestation
and term and detects ⬎98% of trisomy 21 pregnancies. The false-positive rate is
⬍0.5%, although this rate is higher in women at low risk of Down syndrome. The
rate of detection is lower for trisomy 13 and 18. Women with no reportable result
are also at increased risk of fetal aneuploidy.
Screening for Neural Tube Defects
• NTDs are the second most common type of congenital abnormality, after cardiac
anomalies. This group of disorders is characterized by failure of the neural tube to
close or be sealed by normal musculoskeletal coverings during embryogenesis. In-
complete neural tube closure can result in a range of disorders including meningo-
cele, myelomeningocele, or anencephaly. Depending on the severity, some defects
may have potential for surgical correction. The NTDs can be isolated defects or
associated with syndromes and are associated with certain environmental disorders,
maternal diseases, and ethnicities. Primary prevention of NTDs is recommended
with folic acid supplementation (see chapter 9).
• Screening for NTDs should be offered to all pregnant women either with second
trimester MSAFP and/or targeted fetal anatomy ultrasound.
• The MSAFP is a glycoprotein secreted by the fetal liver and yolk sac. Although
not diagnostic, abnormally elevated levels of MSAFP (greater than 2.5 multiples of
the median) are suspicious for open NTDs. Elevated MSAFP can also be detected
in pregnancies complicated by abdominal wall defects, cystic hygroma, teratomas,
fetal demise, multiple gestation, or incorrect pregnancy dating, whereas abnormally
low levels of ␣-fetoprotein may be associated with fetal aneuploidy. Diagnostic
ultrasonography should be performed in cases with abnormal MSAFP.
14 OBSTETRICS
Ultrasonographic Screening
• Ultrasound evaluation of fetal anatomy and placental location should be per-
formed between 18 and 22 weeks’ gestation. Midtrimester ultrasonography seeks
to identify major structural abnormalities (eg, enlarged nuchal translucency,
cystic hygroma, cardiac malformations) and ultrasonographic “soft markers” of
aneuploidy (eg, thickened nuchal fold, pyelectasis, echogenic bowel, short femur
length). However, the sensitivity of ultrasound is widely variable depending on
ultrasonographer experience, machine quality, number of fetuses, and maternal
BMI. Women with high a priori risk of fetal aneuploidy should be offered diag-
nostic testing even when fetal anatomy is thought to appear normal on ultrasound
evaluation.
Diagnostic Testing
• Prenatal diagnostic testing is most commonly done to evaluate for fetal chromo-
somal abnormalities. Fetal cells obtained by either chorionic villus sampling (CVS)
or amniocentesis can then be evaluated using traditional karyotype, fluorescence in
situ hybridization, or chromosomal microarray analysis. Unsensitized Rh-negative
women undergoing prenatal diagnostic testing should receive Rho(D) immune
globulin.
• In chorionic villus sampling, placental tissue is retrieved via transcervical or trans-
abdominal aspiration.
• This procedure is most commonly performed between 10 and 13 weeks of ges-
tation, although the transabdominal approach may be offered throughout the
second and third trimesters. There is no significant difference in the risks of the
two approaches.
• The CVS can be performed at an earlier gestational age than amniocentesis,
allowing earlier diagnosis and thus earlier option for pregnancy termination.
• The risk of CVS-related pregnancy loss is approximately 1:455 (0.22%).
• In 1991, reports of limb defects after CVS were first reported. The risk of
this outcome is decreased when the procedure is performed after 10 weeks’
gestation.
• Other risks of CVS include vaginal spotting, which is more frequent with
the transcervical approach. Amniotic fluid leak or infection after CVS is
very rare.
• Unsensitized Rh-negative women undergoing CVS should receive Rh
immunoglobin.
• Amniocentesis is the transabdominal aspiration of 20 to 30 mL of amniotic fluid.
Amniotic fluid contains fetal cells shed from the fetal gastrointestinal tract, skin,
and bladder.
• This procedure is typically performed between 15 and 20 weeks’ gestation but
can also be performed at more advanced gestational ages.
• Placental puncture should be avoided because fetal blood can contaminate the
specimen and lead to false-positive results.
• Although accurate data are difficult to obtain, the rate of procedure-related
pregnancy loss attributable to prenatal diagnostic procedures is estimated to be
0.1% to 0.3% when performed by experienced health care providers, and over-
all, the pregnancy loss rate for amniocentesis is very low. Other complications,
including vaginal bleeding, leakage of amniotic fluid, and fetal trauma, occur
infrequently, approximately 1% to 2% of all cases.
Labor and Delivery • Stages and Phases of Labor 15
SUGGESTED READINGS
American College of Obstetricians and Gynecologists Committee on Gynecologic Practice.
ACOG Committee Opinion No. 762: prepregnancy counseling. Obstet Gynecol. 2019;133:
e78-e89.
American College of Obstetricians and Gynecologists Committee on Obstetric Practice.
ACOG Committee Opinion No. 650: physical activity and exercise during pregnancy and
the postpartum period. Obstet Gynecol. 2015;126:e135-e142. (Reaffirmed 2019)
American College of Obstetricians and Gynecologists Committee on Obstetric Practice.
ACOG Committee Opinion No. 721: smoking cessation during pregnancy. Obstet Gynecol.
2017;130:e200-e204.
American College of Obstetricians and Gynecologists Committee on Practice Bulletins—
Obstetrics. ACOG Practice Bulletin No. 156: obesity in pregnancy. Obstet Gynecol.
2015;126:e112-e126. (Reaffirmed 2018)
Obstetrics. ACOG Practice Bulletin No. 162: prenatal diagnostic testing for genetic
disorders. Obstet Gynecol. 2016;127:e108-e122. (Reaffirmed 2018)
Obstetrics. ACOG Practice Bulletin No. 163: screening for fetal aneuploidy. Obstet
Gynecol. 2016;127:e123-e137. (Reaffirmed 2018)
American College of Obstetricians and Gynecologists Immunization, Infectious Disease, and
Public Health Preparedness Expert Work Group. ACOG Committee Opinion No. 741:
maternal immunization. Obstet Gynecol. 2018;131:e214-e217. (Reaffirmed 2019)
Normal Labor and

2 Delivery, Operative
Delivery, and
Malpresentations
Samantha de los Reyes and Orlene Thomas
Labor is defined as repetitive uterine contractions of sufficient frequency, intensity,

and duration to cause progressive cervical effacement and dilation.
S TA G E S A N D P H A S E S O F L A B O R
• The first stage of labor begins with the onset of labor and ends with full cervical
dilation. It is divided into latent and active phases.
• The latent phase begins with regular contractions and ends when there is an
increase in the rate of cervical dilation.
• The active phase is characterized by an increased rate of cervical dilation and
descent of the presenting fetal part, which may not occur until after 6 cm
16 OBSTETRICS
of dilation. It ends with complete cervical dilation and is further subdivided

into the following:
¢ Acceleration phase: A gradual increase in the rate of dilation initiates the
active phase and marks a change to rapid dilation.

¢ Phase of maximum slope: the period of active labor with the greatest rate of
cervical dilation
¢ Deceleration phase: the terminal portion of the active phase in which the
rate of dilation may slow until full cervical dilation

• The second stage of labor is the interval between full cervical dilation and delivery
of the neonate.
• The third stage of labor is the interval between delivery of the neonate and deliv-
ery of the placenta.
• The fourth stage of labor, or puerperium, follows delivery and concludes with
resolution of the physiologic changes of pregnancy, usually by 6 weeks postpartum.
During this time, the reproductive tract returns to its nonpregnant state, and ovu-
lation may resume.
MECHANISM OF LABOR
The cardinal movements of labor refer to the changes in position of the fetal head
during its descent through the birth canal in vertex presentation:
• Descent (lightening): movement of the fetal head through the pelvis toward the
pelvic floor. The highest rate of descent occurs during the deceleration phase of the
first stage and during the second stage of labor.
• Engagement: the descent of the widest diameter of the presenting fetal part below
the plane of the pelvic inlet. The widest diameter in cephalic presentation is the
biparietal diameter. In breech presentation, the bitrochanteric diameter determines
the station.
• Flexion: a passive movement that permits the smallest diameter of the fetal head
(suboccipitobregmatic diameter) to pass through the maternal pelvis
• Internal rotation: The fetal occiput rotates from its original position (usually
transverse) toward the symphysis pubis (occiput anterior) or, less commonly, to-
ward the hollow of the sacrum (occiput posterior).
• Extension: The fetal head is delivered by extension from the flexed position as it
travels beneath the symphysis pubis.
• External rotation: The fetal head turns to realign with the long axis of the spine,
allowing the shoulders to align in the anterior-posterior axis.
• Expulsion: The anterior shoulder descends to the level of the symphysis pubis.
After the shoulder is delivered under the symphysis pubis, the remainder of the
fetus is delivered.
MANAGEMENT OF NORMAL LABOR AND DELIVERY

Initial Assessment
History
• Age, parity (full-term deliveries [ⱖ37 wk], preterm deliveries [ⱖ20 to ⬍37 wk],
abortions [⬍20 wk], and living children), estimated gestational age (GA)
• Labor-related symptoms including (1) onset, strength, and frequency of contrac-
tions; (2) leakage of fluid; (3) vaginal bleeding; and (4) fetal movement
Labor and Delivery • Management of Normal Labor and Delivery 17
• Maternal drug allergies
• Medications
• Last oral intake
• Review of prenatal labs and imaging studies including fetal ultrasounds
• Past medical and surgical history, gynecologic history including abnormal Pap smears
and sexually transmitted infections, obstetric history including birth weight and method
of delivery of previous children, social history including tobacco/alcohol/illicit drug use
Physical Exam
• Maternal vital signs (pulse, blood pressure, respiratory rate, and temperature)
• Confirmation of GA, where appropriate, and confirmation of viability at ⱖ approx-
imately 24 weeks
• Assessment of fetal well-being (fetal heart rate [FHR])
• Frequency and intensity of contractions
• Fetal presentation
• Estimated fetal weight (may be performed via Leopold maneuvers, below)
• Step 1: Palpate the fundus to ascertain a fetal pole and obtain fundal height.
• Step 2: Palpate the lateral walls of the uterus to determine fetal lie (vertical vs
transverse) and the location of fetal spine and extremities.
• Step 3: Grasp and palpate the upper and lower poles to determine presentation,
to assess mobility and fetal weight, and to estimate the amniotic fluid volume.
• Step 4: Palpate the presenting part from lateral to medial to assess engagement
in the maternal pelvis, the location of the fetal brow, and the degree of flexion.
• Speculum exam
• Vulvar, vaginal, and cervical inspection (especially noting lesions or scars)
• Evaluate for ruptured membranes: vaginal pooling of fluid in the posterior
fornix, nitrazine test, and ferning seen on microscopic slide.
• Wet mount, gonorrhea/chlamydia screening, group B Streptococcus culture, if
indicated
• Digital exam—defer if estimated GA is ⬍34 weeks with ruptured membranes.
This exam can provide the following data:
• Cervical dilatation is the estimated diameter of the internal os in centimeters.
Ten centimeters corresponds to complete dilation.
• Cervical effacement is the length of the cervix, expressed as the percentage change
from full length, approximately 4 cm. (Zero percent or “long” means not short-
ened at all, whereas 100% means only a paper-thin rim of cervix is detected).
• Fetal station describes the distance in centimeters between the presenting bony
part and the plane of the ischial spines. Station 0 defines the level of the ischial
spines. Below the spines is ⫹1 cm to ⫹5 at the perineum. Station above the
spines is ⫺1 cm to ⫺5 at the level of the pelvic inlet.
• Clinical pelvimetry: evaluation of the maternal pelvis by vaginal exam
¢ Diagonal conjugate: the distance between the sacral promontory and the
posterior edge of the pubic symphysis. A distance of at least 11.5 cm suggests

a sufficiently adequate pelvic inlet for an average-weight fetus.
¢ Transverse diameter: the distance between the ischial tuberosities, which can
be approximated by placing a closed fist of known width at the perineum. An

intertuberous diameter of at least 8.5 cm suggests an adequate pelvic outlet.
• The pelvic type can be classified into four types based on general shape and bony
characteristics. Gynecoid and anthropoid types are most amenable to a successful
vaginal birth.
18 OBSTETRICS
Standard Admission Procedures

• Standard admission labs include urine testing (for protein and glucose), complete
blood count, and a type and screen.
• For patients without prenatal care, hepatitis B surface antigen, human immunode-
ficiency virus, ABO blood group and antibody screen, urine culture and toxicology,
rubella immunoglobulin G, complete blood count, and syphilis screening should be
sent.
• Intravenous access (heplock or continuous infusion) is recommended.
• Informed consent for management of labor and delivery, contraception (if desired)
and for administration of blood products, should they become necessary, should
be obtained.
Management of Labor
• The quality and frequency of uterine contractions should be assessed regularly by
palpation, tocodynamometer, or intrauterine pressure catheter (if indicated).
• The FHR should be assessed by intermittent auscultation, continuous electronic
fetal monitoring, or fetal scalp electrode (FSE) (if indicated).
• Cervical examinations should be kept to the minimum required to detect abnor-
malities in the progression of labor.
• The lithotomy position is the most frequently assumed position for vaginal
delivery in the United States, although birthing positions are highly cultural
and alternative birthing positions, such as the lateral or Sims position or the
partial sitting or squatting positions, are preferred by some patients, physicians,
and midwives.
Induction of Labor
• Indications: Induction of labor is indicated when the benefits of delivery (for the
mother or fetus) outweigh the benefits of continued pregnancy. The favorability
of the cervix at the time of induction is related to the success of labor induction.
When the Bishop score (Table 2-1) exceeds 8, the likelihood of vaginal delivery
after induction is similar to that with spontaneous labor. Induction with a lower
Bishop score has been associated with a higher rate of failure, prolonged labor, and
Table 2-1 Components of the Bishop Scorea
Rating
Factor 0 1 2 3
Dilation Closed 1-2 cm 3-4 cm 5⫹ cm
Effacement 0%-30% 40%-50% 60%-70% 80%⫹
Station ⫺3 ⫺2 ⫺1, 0 ⬎⫹1
Consistency Firm Medium Soft —
Position Posterior Midposition Anterior —
a
Adapted with permission from Bishop EH. Pelvic scoring for elective induction. Obstet Gynecol.
1964;24:267.
Table 2-2 Induction of Labor: Indications and Contraindicationsa
Indications Contraindications
• Abruptio placentae, chorioamnionitis, • Vasa previa or complete
gestational hypertension placenta previa
• Premature rupture of membranes, • Transverse fetal lie
postterm pregnancy, preeclampsia, • Infection—active genital HSV,
eclampsia high viral load HIV
• Maternal medical conditions • Pelvic structural deformities
(eg, diabetes mellitus, renal disease, • Umbilical cord prolapse
chronic pulmonary disease, chronic • Advanced cervical cancer
hypertension)
• Fetal compromise (eg, severe fetal growth
restriction, isoimmunization)
• Fetal demise
• Elective inductions for gestational
age ⬎39 wk
Abbreviations: HIV, human immunodeficiency virus; HSV, herpes simplex virus.

a
Adapted with permission from American College of Obstetricians and Gynecologists Committee on
Practice Bulletins—Obstetrics. ACOG Practice Bulletin No. 107: induction of labor. Obstet Gynecol.
2009;114(2):386-397. (Reaffirmed 2019). Copyright © 2009 by The American College of Obstetricians
and Gynecologists.
cesarean delivery. Induction should not be initiated if vaginal delivery is contrain-

dicated (Table 2-2).
• Cervical ripening may be used to soften the cervix before induction if the
Bishop score is low. Cervical ripening can be achieved using pharmacologic and
mechanical methods.
• Pharmacologic methods of induction of labor and cervical ripening
• Low-dose oxytocin may be used with or without mechanical dilators.
• Prostaglandin E2 is superior to placebo in promoting cervical effacement and
dilation and may enhance sensitivity to oxytocin.
¢ Prepidil gel contains 0.5 mg of dinoprostone in a 2.5-mL syringe; the gel is in-
jected into the cervical canal every 6 hours for up to 3 doses in a 24-hour period.
¢ Cervidil is a vaginal insert containing 10 mg of dinoprostone. It provides a
lower rate of release (0.3 mg/h) than the gel but has the advantage that it can
be removed if uterine tachysystole occurs (⬎5 contractions in 10 min).
• Prostaglandin E1 is also effective in stimulating cervical ripening.
¢ Misoprostol is administered as 25 to 50 mg every 3 to 6 hours intravaginally,
orally, or buccally. The use of misoprostol for cervical ripening is off-label.

• Side effects: Any pharmacologic induction method includes a risk of uterine
tachysystole. If oxytocin is being used, it can be titrated down or turned off
with quick effect due to its short half-life. If Cervidil is being used, the insert
can be removed. If indicated, a ␤-adrenergic agonist (eg, terbutaline sulfate) can
be administered. Maternal systemic effects of prostaglandins may include fever,
vomiting, and diarrhea.
• Contraindications: Cervical ripening agents should be used with caution in
patients with a history of uterine scar or prior cesarean delivery. Caution should
20 OBSTETRICS
be exercised when using prostaglandin E2 in patients with glaucoma or severe

hepatic or renal impairment.
• Mechanical methods of labor induction and cervical ripening
• Membrane stripping (sweeping): increases levels of phospholipase A2 and
prostaglandins and increases likelihood of spontaneous labor within 48 hours
• Amniotomy (artificial rupture of membranes): The risk of umbilical cord pro-
lapse can be reduced by performing the amniotomy while the fetal presenting
part is well applied to the cervix.
• Balloon catheters placed transcervically: a single-balloon device such as a
24-French Foley catheter with inflation volumes of 30 to 80 mL inserted into
the extraamniotic space. Other options are to use larger volume bulb catheters
or a double-balloon device.
¢ Recent evidence suggests that use of a mechanical method of induction with
concurrent use of a pharmacologic agent results in a faster median time to

delivery than single-agent alone.
• Osmotic dilators (laminaria)
Oxytocin Administration
• Indications: Oxytocin is used for both induction and augmentation of labor. Aug-
mentation should be considered for protracted or arrest disorders of labor or the
presence of a hypotonic uterine contraction pattern. A range of options regarding
the dosing of oxytocin exist. A reasonable starting dosage is 0.5 to 4 mIU/min, with
incremental increases of 1 to 2 mIU/min every 20 to 30 minutes. Cervical dilation
of at least 1 cm/h in the active phase indicates that oxytocin dosing is adequate.
If an intrauterine pressure catheter is in place, 180 MVU per 10-minute period
are considered adequate. However, some practitioners use a threshold of 250 to
275 MVU with increased success of induction and minimal adverse consequences.
• Complications: Adverse effects of oxytocin are primarily dose related. The most
common complication is uterine tachysystole (greater than 5 contractions in
10 min), which may result in uteroplacental hypoperfusion and nonreassuring fetal
heart tracings (FHTs). Uterine tachysystole is usually reversible when the oxyto-
cin infusion is decreased or discontinued. If necessary, a ␤-adrenergic agent may
be administered. Rapid infusion of oxytocin can result in hypotension. Prolonged
infusion can result in water intoxication and hyponatremia because oxytocin struc-
turally resembles antidiuretic hormone; prolonged use also increases the risk of
postpartum uterine atony and hemorrhage.
Labor Progress Assessment: Historical and Contemporary

• Dr. Emanuel Friedman’s historic studies on normal labor resulted in widely used
guidelines for normal labor progress.
• Latent phase prolongation is somewhat controversial, as measurement of
this phase is difficult and inexact. Generally speaking, without induction, this
phase is considered prolonged if it exceeds 20 hours in a nulliparous patient and
14 hours in a multiparous patient.
• The active phase is considered protracted if the rate of cervical change is
⬍1.2 cm/h for the nulliparous patient and ⬍1.5 cm/h in the multiparous pa-
tient. Arrest of dilation occurs when there is no apparent cervical change over a
2-hour period despite adequate contractions (180–250 MVU).
• The second stage of labor is considered protracted after 2 hours of pushing in
nulliparous patients or 1 hour in parous patients. An additional hour may be
allowed if epidural anesthesia is used. Arrest of descent occurs when there is no
apparent descent of the presenting part over a 1-hour period of pushing during
the second stage.
• The third stage of labor averages 10 minutes and is considered prolonged if it
lasts longer than 30 minutes.
• More recently, data from the Consortium on Safe Labor suggest a revision of the
definitions of normal and protracted labor to reflect a more contemporary obstetric
population.
• The evidence from this large retrospective study suggests a slower rate of cervical
change than Friedman’s work.
¢ For nulliparous women: 0.5 to 0.7 cm/h
¢ For multiparous women: 0.5 to 1.3 cm/h
• First-stage arrest
• From 4 to 6 cm, nulliparous and multiparous women dilated at approximately
the same rate but still at a slower rate than described by Friedman. From 6 cm
and beyond, multiparous women dilated at a faster rate.
• The active phase did not start until 6 cm.
• The Consortium on Safe Labor did not specifically address duration for diagno-
sis of arrest of labor but recommend diagnosis of arrest of labor to be reserved
beyond 6 cm of dilation. Generally, if a patient remains at ⱖ6 cm for more
than 4 hours in the setting of an adequate contraction pattern or for more than
6 hours without an adequate contraction pattern, she is said to have active phase
arrest of labor.
• Second-stage arrest: no progress (descent or rotation) when pushing for over 3 hours
in nulliparous women and over 2 hours in multiparous women. An additional hour
is allowed if epidural anesthesia is used.
• Abnormal labor may be due to the following:
• Power: inadequate uterine contractions or maternal expulsive effort
• Passenger: size of fetus or abnormal proportions, presentation, or position
• Passage: small pelvis or obstructed birth canal
• Risk factors for abnormal labor could be any medical condition or clinical situa-
tion that affects the categories above.
• Risks for an abnormal first stage of labor: increased maternal age, diabetes, hy-
pertension, premature rupture of membranes, macrosomia (usually defined as
ⱖ4000 g or ⱖ4500 g), epidural anesthesia, chorioamnionitis, a history of previ-
ous complications like perinatal death, and amniotic fluid abnormalities
• Risks for an abnormal second stage of labor: a prolonged first stage, occiput pos-
terior position, epidural anesthesia, nulliparity, short maternal stature, increased
birth weight, and high station at complete cervical dilation
Interventions for Abnormal Labor

• Amniotomy: Artificial rupture of membranes may enhance progress for a patient
who is in active labor. It may increase the risk of chorioamnionitis, although the
evidence has not demonstrated a significant increase in the risk.
• Augmentation of labor via oxytocin: Oxytocin has been shown to decrease the
time of active labor in nulliparous women. In addition, some studies have shown
that it decreases the rate of cesarean delivery for failure to progress.
22 OBSTETRICS
• Uterine contraction monitoring: Placement of an intrauterine pressure catheter

provides information about the frequency and strength of contractions and may be
useful for titrating oxytocin to maximize the chance for successful vaginal delivery.
F E TA L H E A R T R AT E E V A L U AT I O N
The three-tiered guidelines for FHR or FHT interpretation are given in Table 2-3.
• Baseline rate: lasts for at least 2 minutes during a 10-minute section rounded to
the nearest 5 beats/min.
• Normal rate: 110 to 160 beats/min
• Bradycardia: A baseline FHR ⬍110 beats/min. Causes of bradycardia include fetal
head compression, hypoxemia, and maternal hypothermia. The clinical picture is as
important as the heart rate in interpreting fetal bradycardia.
• Tachycardia: A baseline FHR ⬎160 beats/min. The most common cause is maternal
fever or infection. Other less common causes of fetal tachycardia include fetal arrhyth-
mias or maternal administration of parasympatholytic or sympathomimetic drugs.
• Variability: fluctuations in the FHR. It is most reliable when measured with an FSE.
• Absent: absent variability
• Minimal: detectable variability of ⬍5 beats/min
• Moderate: variability of 6 to 25 beats/min
• Marked: variability of ⬎25 beats/min
• Accelerations: For GA ⬎32 weeks, an acceleration is an increase in FHR of at least
15 beats/min that lasts for at least 15 seconds. For GA ⬍32 weeks, an acceleration
is an increase in FHR ⬎10 beats/min for 10 seconds.
• An FHT is reactive if it shows two accelerations within 10 minutes.
• A sinusoidal FHT is a persistent smooth undulating pattern with a frequency
of 3 to 5 cycles/min. It is concerning and requires immediate evaluation. Fetal
anemia; analgesic drugs such as morphine, meperidine, alphaprodine, and butor-
phanol; and chronic fetal distress should be considered.
• Decelerations: a decrease in FHR below the baseline. In some instances, the pat-
tern of deceleration of the FHR can be used to identify the cause.
• Variable decelerations may start before, during, or after the uterine contraction
starts (hence, the designation “variable”). They usually show an abrupt onset to
nadir in ⬍30 seconds and return, which gives them a characteristic V shape.
The decrease is ⬎15 beats/min lasting ⬎15 seconds but ⬍2 minutes. Variable
decelerations are commonly caused by umbilical cord compression.
• Early decelerations are shallow and symmetric and reach their nadir at the peak
of the contraction. They are caused by vagus nerve–mediated response to fetal
head compression.
• Late decelerations are U-shaped decelerations of gradual onset to nadir in
⬎30 seconds and gradual return, reach their nadir after the peak of the con-
traction, and do not return to the baseline until after the contraction is over.
They may result from uteroplacental insufficiency and relative fetal hypoxia.
Recurrent late decelerations can be an ominous sign.
• Prolonged deceleration: a deceleration that lasts longer than 2 minutes but
⬍10 minutes
• Recurrent decelerations: occur with ⬎50% of uterine contractions in any
20-minute span
• Intermittent decelerations: occur with ⬍50% of uterine contractions in any
20-minute span.
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CHAPTER XXIII.
FAMINE AND PLAGUE.
A.H. XVIII. A.D. 639.
The fifth year of Omar’s Caliphate was

darkened by the double calamity of The Year of Ashes. a.h.
pestilence and famine. It is called ‘The XVIII. a.d. 639.
Year of Ashes;’ for the dry air of the Hejâz was so charged with the
unslaked dust of the parched and sandy soil as to obscure the light
by a thick and sultry haze.[356]
In the northern half of the Peninsula the
drought was so severe that all nature Famine in the Hejâz.
languished. Wild and timid creatures of the
desert, tamed by want, came seeking food at the hand of man.
Flocks and herds died of starvation, or were so attenuated as to
become unfit for human food. Markets were empty and deserted.
The people suffered extremities like those of a garrison long
besieged. Crowds of Bedouins, driven by hunger, flocked to Medîna
and aggravated the distress. Omar, with characteristic self-denial,
refused any indulgence which could not be shared with those around
him. He took an oath that he would taste neither meat nor butter, nor
even milk, until the people at large had food enough and to spare.
On one occasion his servant obtained at a great price a skin filled
with milk, and another with butter. Omar sent both away in alms. ‘I
will not eat,’ he said, ‘of that which costeth much; for how then
should I know the trouble of my people, if I suffer not even as they?’
From coarse fare and the use of oil-olive instead of milk and butter,
the Caliph’s countenance, naturally fresh and bright, became sallow
and haggard.[357]
Every effort was made to alleviate
distress, and as the famine was limited to Grain imported from Syria
and other lands.
Arabia, or at any rate was sorest there,
Omar sent letters to the various governors abroad, who promptly
aided him in this extremity. Abu Obeida came himself with four
thousand beasts of burden laden with corn from Syria, which he
distributed with his own hand amongst the famished people. Amru
despatched food from Palestine, both by camels and by shipping
from the port of Ayla.[358] Supplies came also from Irâc. The beasts
of burden were slain by twenties daily, and served, together with
their freight, to feed the citizens of Medîna. After nine months of sore
trial, the heavens were overcast, in answer (we are told) to a solemn
service, in which Abbâs, the Prophet’s aged uncle, took a part; the
rain descended in heavy showers and drenched the land.[359] The
grass sprang rapidly, the Bedouins were sent back to their pasture
lands, and plenty again prevailed. Benefit accrued from the calamity,
for a permanent traffic was established with the north; and the
markets of the Hejâz continued long to be supplied from Syria, and
eventually by sea from Egypt.[360]
The famine was followed, but in a
different region, by a still worse calamity. Plague breaks out in Syria.
The plague broke out in Syria; and,
attacking with special virulence the head-quarters of the Arabs at
Hims and Damascus, devastated the whole province. Crossing the
desert, it spread to Irâc, and even as far as Bussorah. Consternation
pervaded all ranks. High and low fell equally before the scourge.
Men were struck down as by a sudden blow, and death followed
rapidly. Omar’s first impulse was to summon Abu Obeida to his
presence for a time, lest he too should fall a victim to the fell disease.
Knowing the chivalrous spirit of his friend, the Caliph veiled his
purpose, and simply ordered him to visit Medîna ‘on an urgent affair.’
But Abu Obeida divined the cause, and, choosing rather to share the
danger with his people, begged to be excused. Omar, as he read the
answer, burst into tears. ‘Is Abu Obeida dead?’ they asked. ‘No, he
is not dead,’ said Omar; ‘but it is as if he were.’ The Caliph then set
out himself on a journey towards Syria, but was met on the confines
at Tebûk by Abu Obeida and other chief men from the scene of the
disaster. A council was called, and Omar
yielded to the wish of the majority that he Omar holds a council on the
borders of Syria.
should return home again. ‘What,’ cried
some of his courtiers, ‘and flee from the decree of God?’ ‘Yea,’
replied the Caliph, wiser than they, ‘we flee, but it is from the decree
of God, unto the decree of God.’ He then commanded Abu Obeida to
carry the Arab population in a body from the infected cities into the
high lands of the desert, and himself with his followers wended his
way back to Medîna.[361]
Acting on the Caliph’s wish, Abu
Obeida lost no time in leading forth the Arabs of Syria moved to high
people to the high lands of the Haurân. He lands of Haurân.
had reached as far as Jâbia, when just as he put his foot into the
camel’s stirrup to start again upon his onward journey, he too was
struck, and together with his son fell a victim to the pestilence.
Moâdz, whom he had designated to
occupy his place, died almost immediately Death of Abu Obeida.
after; and it was left for Amru to conduct
the panic-stricken multitude to the hill country, where the pestilence
abated. Not less than five-and-twenty thousand perished in this
visitation. Of a single family which migrated seventy in number from
Medîna, but four were left. Such was the deadly virulence of the
plague.
The country was disabled by the
scourge, and at one time fears were Omar’s journey to Syria,
entertained of an attack from the Roman Autumn, a.h. XVIII. a.d. 639.
armies. It was fortunate for the Caliphate that no such attempt was
made, for the Arabs would have been ill able just then to resist it. But
the terrible extent of the calamity was manifested in another way. A
vast amount of property was left by the dead, and the gaps at every
turn amongst the survivors caused much embarrassment in the
administration and devolution of the same. The difficulty grew to
such dimensions, that with the view of settling this and other matters
Omar resolved on making a royal progress through his dominions. At
first he thought of visiting Irâc, and passing through Mesopotamia, so
to enter Syria from the north; but he abandoned the larger project,
and confining his resolution to Syria, took the usual route.[362] His
way lay through the Christian settlement of Ayla, at the head of the
Gulf of Acaba. The reception met with here brings out well the
simplicity of Omar, and his kindly feeling toward the Christians. He
journeyed on a camel with small pomp or following; and as he was
minded to enter the village unrecognised, he changed places with
his servant. ‘Where is the Ameer?’ cried the eager crowds as they
streamed forth from the village to witness the Caliph’s advent. ‘He is
before you,’ replied Omar, and he drove his camel on.[363] So they
hurried forward, thinking that the great Caliph was beyond, and left
Omar to alight unobserved at the house of the bishop, with whom he
lodged during the heat of the day. His coat, which had been rent
upon the journey, he gave to his host to mend. This the bishop not
only did, but had a garment made for him of material lighter and
more suited to the oppressive travel of the season. Omar, however,
preferred to wear his own.
Proceeding onwards to Jâbia, the Caliph made a circuit from
thence over the whole of Syria. He visited
all the Moslem settlements, and gave Muâvia appointed to the chief
instructions for the disposal of the estates command in Syria.
of the multitudes swept away by the plague, himself deciding such
claims as were laid before him. As both Yezîd, the governor of
Damascus, and Abu Obeida had perished in the pestilence, Omar
now appointed Muâvia, son of Abu Sofiân and brother of Yezîd, to
the chief command in Syria, and thus laid the foundation of the
Omeyyad dynasty. Muâvia was a man of unbounded ambition, but
wise and able withal; and he turned to good account his new
position. The factious spirit which built itself up on the divine claim of
Aly and Abbâs, the cousin and uncle of the Prophet, and spurned the
Omeyyad blood of Muâvia, was yet in embryo. Aly, as well as Abbâs,
had hitherto remained inactive at Medîna. The latter, always weak
and wavering, was now enfeebled by age; the former, honoured,
indeed, as well for his wit and judgment as for his relationship to
Mahomet, was amongst the trusted counsellors of the Caliph, but
possessed of no special power or influence, nor any apparent
ambition beyond a quiet life of indulgence in the charms of a harem
varied constantly with fresh arrivals. Neither is there any reason to
suppose that at this time the former opposition to Islam of Abu Sofiân
or of Hind, the parents of Muâvia, was remembered against them.
Sins preceding conversion, if followed by a consistent profession of
the Faith, left no stain upon the believer. It was not till the fires of civil
strife burst forth that the ancient misdeeds of the Omeyyad race and
their early enmity to the Prophet were dragged into light, and political
capital made of them. The accession, therefore, of Muâvia at the
present time to the chief command in Syria excited no jealousy or
opposition. It passed, indeed, as a thing of course, without remark.
[364]
As Omar prepared to take final leave of

Syria, a scene occurred which stirred to Bilâl performs the office of
their depths the hearts of all the Moslems Muedzzin.
present. It was the voice of Bilâl, the Muedzzin of the Prophet,
proclaiming the hour of prayer. The stentorian call of the now aged
African had never been heard since the death of Mahomet; for he
had refused to perform the duty in the service of any other. He
followed the army to Syria, and there, honoured for his former
position, had retired into private life. The chief men now petitioned
Omar that on this last occasion, Bilâl should be asked once more to
perform the office of Muedzzin. The old man consented, and as the
well-known voice arose clear and loud with the accustomed cry, the
people recalled so vividly the Prophet at the daily prayers to mind,
that the whole assembly was melted to tears, and strong warriors,
with Omar at their head, lifted up their voices and sobbed aloud. Bilâl
died two years after, at Damascus.[365]
Omar returned to Medîna in time to set
out on the annual Pilgrimage to Mecca, at Pilgrimage to Mecca, a.h.
which he presided every year of his XVIII. November, a.d. 639.
Caliphate. But this was the last journey which he took beyond the
limits of Arabia.
CHAPTER XXIV.
CONQUEST OF EGYPT.
A.H. XX. A.D. 641.
The year following the plague and

drought was one of comparative repose. a.h. XIX. a.d. 641.
The arms of Islam were now pushing their
way steadily into Persia. But I must reserve the advance in that
direction, and first narrate the conquest of Egypt.
The project is due to Amru. After the fall
of Cæsarea, he chafed at a life of inaction Amru casts an eye on Egypt.
in Palestine, which was now completely
pacified. All around he looked for the ground of some new conquest.
When the Caliph last visited Syria, he sought permission to make a
descent upon Egypt, as every way desirable; for, to gain hold of a
land that was at once weak and wealthy, would enfeeble the power
of the enemy, and, by an easy stroke, augment their own. The
advice was good; for Egypt, once the granary of Rome, now fed
Constantinople with corn. Alexandria, though inhabited largely by
natives of the country, drew its population from every quarter. It was
the second city in the Byzantine empire, the seat of commerce,
luxury, and letters. Romans and Greeks, Arabs and Copts,
Christians, Jews, and Gentiles mingled here on common ground. But
the life was essentially Byzantine. The vast population was provided
in unexampled profusion and magnificence with theatres, baths, and
places of amusement. A forest of ships, guarded by the ancient
Pharos, ever congregated in its safe and spacious harbour, from
whence communication was maintained with all the seaports of the
empire. And Alexandria was thus a European, rather than an
Egyptian, city.[366]
It was far otherwise with the rich valley
irrigated by the Nile. Emerging from the The land of Egypt disaffected
towards Byzantine rule.
environs of the luxurious city, the traveller dropped at once from the
pinnacle of civilisation to the very depths of poverty and squalor.
Egypt was then, as ever, the servant of nations. The overflowing
produce of its well-watered fields was swept off by the tax-gatherers
to feed the great cities of the empire. And the people of the soil,
ground down by oppression, were always ready to rise in
insurrection. They bore the foreign yoke uneasily. Hatred was
embittered here, as in other lands, by the never-ceasing endeavour
of the Court to convert the inhabitants to orthodoxy, while the Copts
held tenaciously by the Monophysite creed. Thus chronic disaffection
pervaded the land, and the people courted deliverance from
Byzantine rule. There were here, it is true, no Bedouin tribes, or
Arabian sympathies, as in the provinces of Syria. But elements of
even greater weakness had long been undermining the Roman
power in Egypt.
It was in the nineteenth or twentieth
year of the Hegira that Amru, having Amru invades Egypt, a.h.
XIX., XX. a.d. 640, 641.
obtained the hesitating consent of the
Caliph, set out from Palestine for Egypt. His army, though joined on
its march by bands of Bedouins lured by the hope of plunder, did not
at the first exceed four thousand men. Soon after he had left, Omar,
concerned at the smallness of his force, would have recalled him;
but finding that he had already gone too far to be stopped, he sent
heavy reinforcements, under Zobeir, one of the chief Companions,
after him. The army of Amru was thus swelled to an imposing array
of from twelve to sixteen thousand men, some of them warriors of
renown.[367]
Amru entered Egypt by Arîsh, and
overcoming the garrison at Faroma, turned And reduces Misr and Upper
to the left and so passed onward through Egypt.
the desert, reaching thus the easternmost of the seven estuaries of
the Nile. Along this branch of the river he marched by Bubastis
towards Upper Egypt, where Mucoucus, the Copt, was governor—
the same, we are told, who sent Mary the Egyptian bond-maid as a
gift to Mahomet.[368] On the way he routed several columns sent
forth to arrest the inroad; and amongst these a force commanded by
his Syrian antagonist Artabûn, who was slain upon the field of battle.
Marching thus along the vale of the Nile, with channels fed from the
swelling river, verdant fields, and groves of the fig tree and acacia,
Amru, now reinforced by Zobeir, reached at last the obelisks and
ruined temples of Ain Shems, or Heliopolis, near to the great city of
Misr.[369] There the Catholicos or bishop procured for Mucoucus a
truce of four days. At its close, an action took place in which the
Egyptians were driven back into their city and there besieged. The
opposition must at one time have been warm, for the Yemen troops
gave way. Reproached by Amru for their cowardice, one of these
replied, ‘We are but men, not made of iron or stone.’ ‘Be quiet, thou
yelping dog!’ cried Amru. ‘If we are dogs,’ answered the angry Arab,
‘then what art thou but the commander of dogs?’ Amru made no
reply, but called on a column of veterans to step forth; and before
their fiery onset the Egyptians fled. But, however bravely the native
army may have fought at first, there was not much heart in their
resistance. ‘What chance,’ said the Copts one to another, ‘have we
against men that have beaten the Chosroes and the Kaiser?’ And, in
truth, they deemed it little loss to be rid of the Byzantine yoke. The
siege was of no long duration. A general assault was made, and
Zobeir, with desperate valour, had already scaled the walls, and the
place was at the mercy of the Arabs, when a deputation from
Mucoucus obtained terms from Amru. A capitation tax was fixed of
two dinars on every male adult, with other impositions similar to
those of Syria. Many prisoners had already been taken; and a fifth
part of their number, and of the spoil, was sent to Medîna. The same
conditions were given to the Greek and Nubian settlers in Upper
Egypt. But the Greeks, fallen now to the level of those over whom
they used to domineer, and hated by them, were glad to make their
escape to the sea coast.[370]
Amru lost no time in marching upon
Alexandria, so as to reach it before the Alexandria, besieged,
Greek troops, hastily called in from the
outlying garrisons, could rally there for its defence. On the way he
put to flight several columns which sought
to hinder his advance; and at last capitulates a.h. XX. a.d. 641.
presented himself before the walls of the great city, which, offering
(as it still does) on the land side a narrow and well-fortified front, was
capable of an obstinate resistance. Towards the sea also it was open
to succour at the pleasure of the Byzantine Court. But during the
siege, Heraclius died, and the opportunity of relief was supinely
allowed to slip away.[371] Some of the protective outworks on the
narrow isthmus were taken by storm; and there appearing no
prospect of support from Constantinople, the spirit of the garrison
began to flag. The Greeks took to their ships, and in great numbers
pusillanimously deserted the beleaguered city. At last Mucoucus,
who after his defeat had retired to Alexandria, finding the place too
weak for a prolonged defence, offered to capitulate, on the same
terms as were given to Upper Egypt, and on condition that the
prisoners taken throughout the campaign were set free. The Caliph,
being referred to, readily agreed. ‘Tribute,’ he replied, ‘is better than
booty; for it continueth, whereas spoil soon vanisheth as if it had not
been. Touching the captives, such as are already scattered, are
beyond my power; but those that remain, saving such as were
seized on the field of battle, shall be restored.’ And so the city
escaped sack, and the people became tributary to the conquerors.
[372]
Amru, it is said, wished to fix his seat of

government at Alexandria, but Omar would Amru founds Fostât, or
not allow him to remain so far away from Cairo.
his camp, with so many branches of the Nile between. So he
returned to Upper Egypt. A body of the Arabs crossed the Nile and
settled in Ghîzeh, on the western bank—a movement which Omar
permitted only on condition that a strong fortress was constructed
there to prevent the possibility of their being surprised and cut off.
[373] The head-quarters of the army were pitched near Memphis.
Around them grew up a military station, called from its origin Fostât,
or ‘the Encampment.’ It expanded rapidly into the capital of Egypt,
the modern Cairo.[374] And there Amru laid the foundations of a
great Mosque, which still bears his name.
Zobeir urged Amru to enforce the right
of conquest, and divide the land among his The soil left in the hands of
the cultivators.
followers.[375] But Amru refused; and the
Caliph, as might have been expected, confirmed the judgment.
‘Leave the land of Egypt,’ was his wise reply, ‘in the people’s hands
to nurse and fructify.’ As elsewhere, Omar would not allow the Arabs
to become proprietors of a single acre. Even Amru was refused
ground whereupon to build a mansion for himself. He had a dwelling-
place, the Caliph reminded him, at Medîna, and that should suffice.
So the land of Egypt, left in the hands of its ancestral occupants,
became a rich granary for the Hejâz, even as in bygone times it had
been the granary of Italy and the Byzantine empire.
A memorable work, set on foot by Amru
after his return from Alexandria to Fostât, Amru reopens
facilitated the transport of corn from Egypt communication between the
Nile and Suez. a.h. XXI. a.d.
to Arabia. It was nothing less than the 641–2.
reopening of the communication of old
subsisting between the waters of the Nile in Upper Egypt and those
of the Red Sea at Suez. The channel followed the most eastern
branch of the river as far north as Belbeis, then turned to the right
through the vale of Tumlât, and, striking the Salt Lakes near Timseh,
so reached the Red Sea by what is now the lower portion of the
Suez Canal. Long disused, the bed, where shallow and artificial, had
in that sandy region become choked with silt. The obstructions,
however, could not have been very formidable, for within a year they
were cleared away by the labour of the Egyptians, and navigation
thus restored. The Caliph, going down to Yenbó (the Port of
Medîna), there saw with his own eyes vessels discharge the burdens
with which they had been freighted by Egyptian hands under the
shadow of the Pyramids of Ghîzeh. The Canal remained navigable
till the reign of Omar II., that is, for eighty years, when, choked with
sand, it was again abandoned.[376]
Finding that the Egyptians, used to the
delicate and luxurious living of their land, Amru would teach the
natives to respect the Arabs.
looked down upon the Arabs for their
simple and frugal fare, Amru chose a singular expedient to disabuse
them of the prejudice, and raise his people in their estimation. First
he had a feast prepared of slaughtered camels, after the Bedouin
fashion; and the Egyptians looked on with wonder while the army
satisfied themselves with the rude repast. Next day he commanded
a sumptuous banquet to be set before them, with all the dainties of
the Egyptian table; and here again the warriors fell to with equal
zest. On the third day there was a grand parade of all the troops in
battle array, and the people flocked to see it. Then Amru addressed
them, saying: ‘The first day’s entertainment was to let you see the
plain and simple manner of our life at home; the second to show you
that we can, not the less, enjoy the good things of the lands we
enter; and yet retain, as ye see in the spectacle here before you, our
martial vigour notwithstanding.’ Amru gained his end; for the Copts
retired saying one to the other, ‘See ye not that the Arabs have but to
raise their heel upon us, and it is enough!’ Omar was delighted at his
lieutenant’s device, and said of him, ‘Of a truth it is on wisdom and
resolve, as well as on mere force, that the success of warfare doth
depend.’
A curious tale is told of the rising of the
Nile and of Omar’s rescript in reference to Fable of a maiden sacrifice
the same. The yearly flood was long and Omar’s rescript.
delayed; and, according to wont, the Copts desired to cast into the
river a maiden beautifully attired. When asked what course should
be pursued to meet their wish, the Caliph indited this singular letter,
and inclosed it in a despatch to Amru:—
‘The Commander of the Faithful to the River Nile, greeting. If in
times past thou hast risen of thine own will, then stay thy flood; but if
by the will of Almighty God, then to Him we pray that thy waters may
rise and overspread the land.
‘Omar.’
‘Cast this letter,’ wrote the Caliph, ‘into the stream, and it is
enough.’ It was done, and the fertilising tide began to rise
abundantly.[377]
The seaboard of Africa lay open to the naval power of the
Byzantine empire; but for a time, it was little used against the
Saracens. Amru, with the restless spirit of
his faith, soon pushed his conquests Alexandria retaken,
westward beyond the limits of Egypt, besieged, and finally
reoccupied by Moslems. a.h.
established himself in Barca, and reached XXV. a.d. 646.
even to Tripoli.[378] The subject races in
these quarters rendered their tribute in a fixed quota of African
slaves, thus early legalising in that unhappy land the iniquitous traffic
which has ever since prevailed in human flesh and blood. The
maritime settlements and native tribes thus ravaged, received little or
no aid from the Byzantine fleets. But early in the Caliphate of
Othmân, a desperate attempt was made to regain possession of
Alexandria. The Moslems, busy with their conquests elsewhere, had
left the city insufficiently protected. The Greek inhabitants conspired
with the Court; and a fleet of three hundred ships was sent under
command of Manuel, who drove out the garrison and took
possession of the city. Amru hastened to its rescue. A great battle
was fought outside the walls: the Greeks were defeated, and the
unhappy town was subjected to the miseries of a second and a
longer siege. It was at last taken by storm and given up to plunder.
To obviate the possibility of another similar mishap, Amru razed the
fortifications, and quartered in the vicinity a strong garrison, which,
every six months, was relieved from Upper Egypt. The city, though
still maintaining its commercial import, fell now from its high estate.
The pomp and circumstance of the Moslem Court were transferred
to Fostât, and Alexandria ceased to be the capital of Egypt.[379]
CHAPTER XXV.
ADVANCE ON THE SOUTHERN BORDER OF PERSIA—
HORMUZAN TAKEN PRISONER.
A.H. XVI.-XX. A.D. 637–641.
Turning once more to the eastern

provinces of the Caliphate, we find the Barrier laid down by Omar
cautious policy of Omar still tending to towards the East.
restrain the Moslem arms within the limits of Irâc-Araby; that is,
within the country bounded by the western slopes of the great range
which separates Chaldæa from Persia proper. But they were soon,
by the force of events, to burst the barrier.
To the north of Medâin, the border land
of Moslem territory was securely defended Situation in Lower Irâc.
by Holwân and other strongholds, already
mentioned as planted along the hilly range. In Lower Irâc, Otba, as
we have seen, had, after repeated encounters, established himself
at Bussorah, from whence he held securely the country at the head
of the Gulf.[380] But the Persian satraps, though keeping at a safe
distance aloof, were still in strength at Ahwâz and Râm Hormuz
within a hundred miles of him.
Hostilities in this direction were
precipitated by a rash and unsuccessful The Governor of Bahrein
raid, from the opposite coast, upon Istakhr attacks Persepolis. a.h. XVI.
a.d. 637.
or Persepolis.[381] Alâ, Governor of
Bahrein, who had distinguished himself in crushing the rebellion
along the southern shore of the Persian Gulf, looked on with jealous
eye at the conquests made in Irâc by Sád. Tempted by the closeness
of the Persian shore, he set on foot an expedition to cross the
narrow sea, and seize the district which lay opposite. This was done,
not only without the permission of Omar, but against his known
unwillingness to trust the treacherous element.[382] Success might
have justified the project; but it fell out otherwise. The troops
embarked with alacrity; and landing (it may have been) at Bushire,
met for a time with no check in their advance upon Persepolis. But
before long they were drawn into a trap.
Advancing confidently with their whole Meets with a check, but is
force in three columns, they had neglected relieved from Bussorah.
to secure their base; and the Persians, coming behind, cut them off
altogether from their ships. The Moslems, after a severe
engagement, in which the leaders of two of the columns fell, were
unable to disperse the gathering enemy; and, turning as a last
resource towards Bussorah, found the road in that direction also
barred. Messengers were hurried to Medîna, and Omar, highly
incensed with Alâ for his foolhardiness, despatched an urgent
summons to Otba to relieve from Bussorah the beleaguered army. A
force of 12,000 men set out immediately; and forming, not without
difficulty, a junction with Alâ, beat back the Persians, and then retired
on Bussorah. The troops of Otba gained a great name in this affair,
and the special thanks of Omar.
But the retreat, conducted with
whatever skill and bravery, put heart into Campaign in Khuzistan. a.h.
XVII. a.d. 638.
the hostile border. Hormuzân, a Persian
satrap, escaping from the field of Câdesîya, had retired to his own
province of Ahwâz, on the lower mountain range, at no great
distance from Bussorah. He began now to make raids upon the
Moslem outposts, and Otba resolved to attack him. Reinforcements
were obtained from Kûfa, and Otba was also fortunate enough to
gain over a strong Bedouin tribe, which, though long settled in the
plain below Ahwâz, was by blood and sympathy allied to the Arab
garrison of Bussorah. Thus strengthened, he dislodged the enemy
from Ahwâz, and drove him across the Karoon river. A truce was
called; and Ahwâz, having been ceded to the Moslems, was placed
by Otba in the hands of his Bedouin allies.[383] A dispute as to their
boundary, however, shortly after arose between the Bedouins and
Hormuzân; and the latter, dissatisfied with the Moslem decision,
again raised his hostile standard. He was put to flight by Horcûs, a
‘Companion’ of some distinction, who reduced the rebellious
province, and sought permission to follow up his victories by a
farther advance. But Omar, withholding
permission, bade him occupy himself in a.h. XVIII. a.d. 639.
restoring the irrigation works, and
resuscitating the deserted fields, of Khuzistan. Hormuzân fled to
Râm Hormuz, farther east, and was, for the second time, admitted to
an amnesty.
Not long after, tidings reached Horcûs,
that emissaries from Yezdegird at Merve Râm Hormuz and Tostar
taken. a.h. XIX. a.d. 640.
were stirring up the people to fresh
opposition. The attitude of Hormuzân became once more doubtful;
and the Caliph, suspecting now a serious combination, assembled a
powerful army from Kûfa and Bussora, and gave the command to
Nómân ibn Mocarrin.[384] Hormuzân, with a great Persian following,
was again routed, and, having abandoned Râm Hormuz to the
Arabs, fled to Tostar,[385] fifty miles north of Ahwâz. This stronghold
was obstinately defended by the Persians, who rallied there in great
force, and kept the Moslems for several months at bay. In the end,
but not without considerable loss, the citadel was stormed, and
Hormuzân, with the garrison, subject to the decision of the Caliph,
surrendered at discretion. They were meanwhile put in chains; and
Hormuzân was sent to answer before the Caliph for his repeated
rebellion and breach of faith.’[386]
The troops then laid siege to Sûs, the
royal Shushan of ancient memories, and Capture of Sûs (Shushan).
still a formidable city, planted as it was
between two rivers, on a verdant plain with snow-clad mountains in
the distance. The Arabs were here fortunate in drawing over to their
side a body of Persian nobles with an important following; these
were at once admitted to confidence; commands were conferred
upon them, and they had the singular honour of a high place on the
Caliph’s civil list. Still it was not till after a protracted siege and
conflict that Sûs was taken. Omar gave
orders for the reverential maintenance of The tomb of Daniel.
the tomb of Daniel in this the scene of his
memorable vision ‘by the river of Ulai;’ and here, to the present day,
the pious care of succeeding generations has preserved his shrine
on the river bank through thirteen centuries of incessant change.[387]
The important city of Jundai-Sabûr, with
the country around the sources of the Jundai-Sabûr occupied.
Karoon, was also reduced by Nómân. But
events were already transpiring in Khorasan, which at length opened
the way to an advance upon the heart of Persia, and called away
that leader to more stirring work.
The narrative of the deputation which,
together with the spoil of Tostar, carried Hormuzân sent a captive to
Hormuzân a prisoner to Medîna, will throw Medîna.
light on the reasons which weighed with the Caliph, and led to the
withdrawal of the embargo upon a forward movement eastward. As
they drew nigh to Medîna, his conductors dressed out their captive in
his brocaded vestments, to show the people there the fashion of a
Persian noble. Wearied with the reception of a deputation from Kûfa
(for in this way he transacted much of the business from the
provinces), Omar had fallen asleep, as he reclined, whip in hand, on
his cushioned carpet in the Great Mosque. When the party entered
the precincts of the court, ‘Where is the Caliph?’ asked the captive
prince, looking round, ‘and where the guards and warders?’ It was,
indeed, a marvellous contrast, that between the sumptuous palaces
of the Chosroes, to which he had been used, and the simple
surroundings of the mightier Caliph! Disturbed by the noise, Omar
started up, and, divining who the stranger was, exclaimed, ‘Blessed
be the Lord, who hath humbled this man and the like of him!’ He
bade them disrobe the prisoner of his rich apparel and clothe him in
coarse raiment. Then, still whip in hand, he upbraided the denuded
captive and (Moghîra interpreting) bade him justify the repeated
breach of his engagements. Hormuzân made as if fain to reply; then
gasping, like one faint from thirst, he begged for a draught of water.
‘Give it to him,’ said the Caliph, ‘and let him drink in peace.’ ‘Nay,’
said the captive trembling, ‘I fear to drink, lest some one slay me
unawares.’ ‘Thy life is safe,’ replied Omar, ‘until thou hast drunk the
water up.’ The words had no sooner passed his lips than Hormuzân
poured the contents of the vessel on the ground. ‘I wanted not the
water,’ he said, ‘but quarter, and now thou hast given it me.’ ‘Liar!’
cried Omar in anger, ‘thy life is forfeit.’ ‘But not,’ interposed the
bystanders, ‘until he drink the water up.’ ‘Strange,’ said Omar, foiled
for once, ‘the fellow hath deceived me, and yet I cannot spare the life
of one who hath slain so many noble Moslems by his reiterated
treachery. I swear that thou shalt not gain by thy deceit, unless thou
shalt forthwith embrace Islam.’ Hormuzân, nothing loth, made
profession of the Faith upon the spot; and thenceforth, taking up his
residence at Medîna, received a pension of the highest grade.[388]
‘What is the cause,’ inquired Omar of
the deputation, ‘that these Persians thus Deputation urge removal of
persistently break faith and rebel against the ban against advance.
us? Maybe, ye treat them harshly.’ ‘Not so,’ they answered; ‘but thou
hast forbidden us to enlarge our boundary; and the king is in their
midst to stir them up. Two kings can in no wise exist together, until
the one of them expel the other. It is not our harshness, but their
king, that hath incited them to rise up against us after that they had
made submission. And so it will go on until that thou shalt remove
the ban and leave us to go forward, occupy their cities, and expel
their king. Not till then will their vain hopes and machinations cease.’
These views were, moreover, enforced
by Hormuzân. And the truth began now to Omar begins to see this.
dawn on Omar that necessity was laid
upon him to withdraw the ban against advance. In self-defence,
there was nothing left for him but to crush the Chosroes and take
entire possession of his realm.

The Johns Hopkins Manual of Gynecology and Obstetrics South Asian Edition Betty Chou Full Chapter

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The Johns Hopkins Manual of

Gynecology and Obstetrics South

Jessica L. Bienstock, md, mph

First Indian Reprint, 2020

Indian Reprint ISBN : 978-93-89859-66-9

Published by Wolters Kluwer (India) Pvt Ltd, New Delhi

If you have difficulty buying LWW books,

Online resources are not available with this text.

Crystal Aguh, MD Deborah K. Armstrong, MD

Carla Bossano, MD Jensara Clay, MD

Irina Burd, MD, PhD Jenell S. Coleman, MD, MPH

Danielle B. Chau, MD Kristin Darwin, MD

Katherine F. Chaves, MD Samantha de los Reyes, MD

Chi Chiung Grace Chen, MD, MHS Rita W. Driggers, MD

Mindy S. Christianson, MD Jill Edwardson, MD, MPH

Katerina Hoyt, MD Chavi Kahn, MD, MPH

Lea A. Moukarzel, MD Elizabeth Oler, MD

Jamie Murphy, MD Lauren M. Osborne, MD

Victoire Ndong, MD Silka Patel, MD, MPH

Donna Maria Neale, MD Kristin Patzkowsky, MD

Christopher M. Novak, MD Jennifer A. Robinson, MD, MPH,

Lauren Thomaier, MD Karen C. Wang, MD

Julia Timofeev, MD MaryAnn Wilbur, MD, MPH, MHS

2 Normal Labor and Delivery, Operative Delivery,

3 Complications of Labor and Delivery 33

6 Preterm Labor and Preterm Prelabor Rupture of Membranes 65

9 Congenital Anomalies 109

10 Multifetal Gestation 123

11 Endocrine Disorders of Pregnancy 130

12 Hypertensive Disorders of Pregnancy 154

13 Cardiopulmonary Disorders of Pregnancy 166

14 Genitourinary Assessment and Renal Disease in Pregnancy 183

15 Gastrointestinal Disease in Pregnancy 190

16 Autoimmune Disease in Pregnancy 197

17 Neurologic Diseases in Pregnancy 210

18 Psychiatric Disorders in the Pregnant and Postpartum Patient 221

19 Substance Use Disorders in Pregnancy 237

20 Hematologic Disorders of Pregnancy 254

21 Neoplastic Diseases in Pregnancy 281

22 Skin Conditions in Pregnancy 294

23 Surgical Disease and Trauma in Pregnancy 298

24 Postpartum Care and Breastfeeding 308

25 Obstetric Anesthesia 319

Part II: General Gynecology 329

27 Infections of the Genital Tract 346

28 Contraception and Sterilization 373

30 First and Second Trimester Pregnancy Loss and

31 Abnormal Uterine Bleeding 402

32 Chronic Pelvic Pain 416

33 Uterine Leiomyomas and Benign Adnexal Masses 434

34 Breast Diseases 446

35 Benign Vulvar Disorders 461

36 Female Sexual Function and Dysfunction 469

37 Intimate Partner and Sexual Violence 478

38 Pediatric Gynecology 487

Part III: Reproductive Endocrinology

40 Infertility and Assisted Reproductive Technologies 507

41 Recurrent Pregnancy Loss 526

42 Menstrual Disorders: Endometriosis, Dysmenorrhea, and

43 Evaluation of Amenorrhea 544

44 Polycystic Ovary Syndrome and Hyperandrogenism 556

45 Definitions and Epidemiology of Menopause 570

Part IV: F emale Pelvic Medicine and

Part III: Reproductive Endocrinology

Part IV: F emale Pelvic Medicine and