FOGSI’s Postgraduate Obstetrics: A Textbook (Volume 1) Ameya Purandare, Parikshit Tank, Alpesh Gandhi
Page numbers followed by b refer to box, f refer to figure, fc refer to flowchart, and t refer to table.
Abatacept 313
Abdomen 306
causes of acute 428, 429, 432t
surgical 428
Abdominal closure 615
Abdominal contour 556f
Abdominal examination 92, 556, 565
Abdominal fat, excessive 350
Abdominal organs 176
Abdominal pain 99, 304, 306, 439
acute 428
Abdominal situs 175, 176
Abdominal tenderness 430
Abdominal tilt, maternal 437
Abdominal trauma 544
Abdominal wall 630
Abortion 193, 201
classification 193
clinical grading of 196t
complete 193, 195
etiology of 194
first-trimester 194, 197
incidence 193
incomplete 193, 195, 292
induced 194, 197
inevitable 193, 195, 195f
medical 730
missed 193, 195
pathology of 194
recurrent spontaneous 544
second-trimester 194, 197
spontaneous 193, 201, 461
threatened 193, 194
unsafe 198
Abruptio placenta 154, 267, 522, 524f, 526f, 653
complications of 524t
Abruption 227, 688
Abscess 667
epidural 625
Absent end-diastolic volume 492
Absolute lymphocyte count 394
Acardiac twin 464
Accredited Social Health Activist 729, 734
Acetaminophen 444
poisoning 444
Acetylcholine esterase inhibitors 313, 404
Acetylsalicylic acid 252
balance 107
changes 108t
equilibrium 82
monitoring 759
Acid-fast bacilli 321
Acidosis 154, 297, 697
Acid-suppressing drugs 305
Acne vulgaris 336
Acquired immunodeficiency
disease 367
syndrome 367
Acquired thrombophilia 227, 543
Acrania 75
Acrosome reaction 54
Act of violence 51
Actim® Partus kit 505f
Actinomycin 206
Activated charcoal 444
Activated partial thromboplastin time 252, 311
Acupressure 622
Acupuncture 622
Acute kidney injury 292, 293, 293t, 294
Acute respiratory distress syndrome 324, 524, 745
pregnancy-specific 324
severe 774
Acute seizure
differential diagnosis of 328f
intrapartum management of 331fc
Adalimumab 313
Addison disease 267
Adenocarcinoma 295
Adhesion 57
Adipocytes 259
Adipokines 348
Adnexal torsion 364
Adrenal hyperplasia, congenital 715
Adrenal tumor 235
Adrenaline 779
Adult advanced life support 772
Adult basic life support 772
Advance fetal echocardiography 175
Advanced cardiac
life support 775
support 437
Advanced magnetic resonance techniques 701
Agalactia 631
Airborne transmission 387
Airway 756
Ajit Rawal method 647, 648f
aminotransferase 401, 408
transaminase 302
Albumin infusions 296
Alcohol 97
abuse, chronic 447
poisoning 447
use screening tools 342t
Alcoholic liver disease 418
Alkali denaturation tests 286
Alkalosis 324
Alleles 114
Allergic rhinitis 336
Allograft function 303
Alloimmune factors 194
Alloimmunization 158
Alpha-fetoprotein 135
Alpha-thalassemia 279, 284, 285, 540
minor 285
Aluminum containing antacids 305
Alveolar glands 38
Ambiguous genitalia 715, 718
Ambu bag 691
Amenorrhea 417
Amikacin 667
Amino acids 259, 302, 304
salicylic 306, 315
Aminoglycosides 323, 390
Amiodarone 779
use of 267
Ammonia 304
Amniocentesis 135, 149, 152, 186, 191, 282, 297, 461, 505
advantages of 152
gestational age 149
procedure of 150
tests 150
Amnioinfusion 472, 473, 593
Amnion 459
Amnionitis 154
Amniotic cavity, microbial infection of 484, 505f
Amniotic fluid 144, 321, 470, 514f, 546
abnormal levels of 472t
amount of 162
embolism 325, 522, 770
index 472, 486, 488, 490, 496
pocket 471f
resorption of 470
samples 284
sludge 504
water, circulation of 470f
Amniotic fluid volume 401, 470f
abnormalities of 470
assessment of 158, 471
dynamics of 470
sonographic assessment of 158
Amniotomy 582, 739
Amoxicillin 305, 515
Amphetamines 342
Ampicillin 515
Anaemia Mukt Bharat 380
Anakinra 313
Anal agenesis 715
Anal epithelium 639
Analgesia 621
during labor, indications of 624
Analgesics 282, 674
Anaphylactic reaction 779
Anaphylaxis 771
Ancylostoma duodenale 380
Androgenetic complete hydatidiform mole 211
Anecdotal herbal galactagogues 677
Anemia 273, 279, 320, 461
causes of 274
correction of 275
cycle 274fc
eradication of 277
mild 286
moderate-to-severe 277
postpartum 275, 276
prevention of 297
severe 544
severity of 273t
tests to diagnose 274
treatment of 276, 297
Anencephaly 74, 147, 147f, 542f
Anesthesia 150, 531, 621, 779
Aneuploidy 114, 120, 194, 298, 542
markers 129
screening 95, 128
ultrasonography for 129
Angelman syndrome 68, 117
Angiogenesis 358
Angiotensin-converting enzyme inhibitors 244, 295, 310, 325
Angiotensin-receptor blockers 310
Anisocytes 286
Ankyloglossia 671
Anomaly scan 230
Antacids 305
Antenatal anti-D immunoglobulin 95
Antenatal care 89, 97, 236, 302, 499, 727
components of 94t
contacts 89, 90t
model 89
package 92
pyramids 128f
utilization of 96
Antenatal complications 461, 508
Antenatal exercises 425
Antenatal information 632
Antenatal management 330
Antenatal pharmacologic therapy 425
Antenatal protocols 230
Antenatal screening 95, 330
Antenatal steroid
role of 240
trial 34
Antenatal wellbeing tests 698
Antepartum fetal
assessment 158
methods of 158
surveillance tests 157, 410, 537
Antepartum management 245
Anterior diaphragmatic defects 78
Anthelmintic treatment, preventive 95
Anthropoid 45
Antiangiogenic drugs 358
Antiarrhythmic drugs 253t
Antiarrhythmic therapy 253
Antibiotic 6, 150, 315, 389, 505, 514
intravenous 197
prophylaxis 247t, 297
therapy 667
loss of 374
phospholipid-dependent 311
Anticardiolipin 311
antibody 199, 235
positive for 311
Anticholinergics 304
Anticoagulants 253, 395
prophylaxis 252
Anticonvulsants 194
Anti-D immunoglobulin 437
Anti-D immunoprophylaxis 633
Antiemetics 99
Antiendomysial antibodies 68
Antiepileptic drug 327, 329t, 331
Antiestrogenic hormonal therapy 358
Antihistamines 99
Antihypertensive agents 238
Antihypertensive medications 240
Antimalarials, use of 317
Antimicrobials, role of 506
Antimicrosomal antibody 235, 267
Antineutrophil cytoplasmic antibody 315
Antinuclear antibody 198, 235
Antiobesity 353
Antiperoxidase 267
antibody syndrome 230, 303, 309, 485
autoantibody 311
syndrome 158, 194, 201, 311, 541, 543
Antiretroviral drugs 368, 369t
classes of 368t
Antiretroviral therapy 367, 371b, 384
Anti-Rh immunoglobulin 546
Anti-rheumatic drugs, disease-modifying 312
Antisepsis 6
Antithyroglobulin 267
Antithyroid medications 269, 314
Anti-tumor necrosis factor, use of 313
Anti-vascular endothelial growth factor 358
Anxiety 341, 779, 768
generalized 340
coarctation of 235
diseases of 255
posterior wall of 180f
size index 249, 250
Aorta-gonad-mesonephros 76
Aortic arch 184f
transverse 183f
Aortic dissection 255
Aortic isthmus 168f
Aortic origin 177
Aortic regurgitation 251
Aortic stenosis 251
causes of 251
Aortic valve 180f, 251
Aplastic crisis 281
Appendages 336
Appendicitis 306, 388
Appendix 306
Arabin cervical pessary 508f
Areola 81f
Arginine butyrate infusions 282
Arnold-Chiari malformation 75
Arrhythmia 253, 287
Arterial blood gas 318t, 322, 331, 443, 754, 760
estimation of 330
Arterial blood pressure 85
Arterial hypertension 348
Arterial invasive blood pressure monitoring 758
Arterial perfusion sequence, twin reverse 464, 542
Arterial pressure, shape of 758
Arteriovenous malformation 331, 610
Arthralgia 310
Arthrogryposis multiplex congenita 496
Arthropathy 323
Artificial intelligence 26
Ascaris lumbricoides 380
Ascites 304, 401
Aseptic bone necrosis 281
Asherman syndrome 194
Aspartate aminotransferase 408, 412
Aspartate transaminase 302, 401
Asphyxia 463, 697
laboratory evaluation of 699
Aspirin 238, 296, 403
low-dose 230, 312, 491
Asplenia, functional 281
Assisted breech delivery 559, 561
Assisted reproductive technology 135, 228, 256, 457, 460, 512
Asthma 321, 336
acute severe 322
clinical features of 321
during labor, management of 322
exacerbation, acute 322
triggers 321
control of 321
uncontrolled 321
Asymptomatic bacteriuria 95, 283
Ataxia 344
Atelectasis 283
Atenolol 237
Atopic dermatitis develops 336
Atosiban 506, 507
Atria 175
Atrial septal defect 247, 248, 254
Attention-deficit disorder 68, 274, 344
Auditory nerve agenesis 303
Autism attention-deficit hyperactivity disorder 350
defects 194, 230, 270, 544
diseases 739
disorders 68, 308, 311
number of 308
hepatitis 417
vasculitis 314
Automated external defibrillation 772, 774, 777
Autosomal dominant disorders 116b
Autosomal recessive disorders 116b, 288
Auxiliary nurse midwife 734
Avascular necrosis 281
Axilla, management of 361
Axillary lymph node dissection 361
Azathioprine 296, 303, 314, 315, 317, 418
Azithromycin 323, 505
Azoospermic factor C deletion 68
Azygous system 301
Baby's heart rate 689
Back pressure 473
Bacteria 451
Bacterial contamination 768
Bacterial infections 380, 385, 451
Bacterial respiratory infections 323
Bacterial vaginosis 94, 375, 387, 504, 512
Bacteroides 387, 504
Bakri balloon 646
Balanced chromosomal structural rearrangements 120
Balloon occlusion catheters 532
Bariatric surgery 306, 354
Barkers hypothesis 414
Bartholin's glands 38, 38f
Basal pneumonia 430
Basic fetal echocardiography 175
Basic life support 777fc
Battledore placenta 482
Beau's lines 336
Bedside clot observation test 525
Bell's palsy 332
Benson and Durfee cerclage 201
Benzene 194
Benzodiazepines 342, 448
poisoning 444
Beta hemolytic streptococci, group B 384
Beta-1 glycoprotein 110
Beta-adrenergic receptors agonists 507
Beta-blockers 237
Beta-cell function 119
Beta-human chorionic gonadotropin 134, 135, 170, 297
Beta-lactamase-resistant penicillins 674
Betamethasone 505
Beta-thalassemia 279, 284, 286
hallmark of 286
major 286, 286f, 287
minor 286
Bicornuate uterus 194
Bicuspid aortic valve 256
Biguanide 261
Bilaminar germ disk, formation of 70f
Bilateral renal
agenesis 472
dysplasia 472
Bile acids, accumulation of 410
Biliary cholangitis, primary 416
Biliary cirrhosis, primary 416
Bilirubin levels 410
Bilirubinemia 756
Bilobate placenta 478
Binovular twins 457
Biochemical parameters 357
Biochemical screening 133
Biochemical test 133, 461
Biophysical profile 157, 161, 488, 490, 492
interpretation of 161t
modified 157, 161, 410
reliability of 162
score 161t
Biopsy 320, 360
Biparental complete hydatidiform mole 211, 212, 213f
Biparental familial recurrent mole 213f
Biparietal diameter 140f
measurement of 486
Bird's modifications 599
asphyxia 227
canal 629
defects, types of 66
preparedness 96
timing of 489
Birth injuries 704
classification 705
ranges, spectrum of 704
risk factors 704
Bishop's score 578, 585, 579fc, 580fc
modified 578, 578t
Bladder 235
care 569, 632
dissected down 658f
dissection of 658
exstrophy 78
identification of 655f
overdistension 473
rupture 473
sharp dissection, dissection of 658f
Blastocyst 57
Blastulation 69f
Bleeding 655, 778
amount of 520t
causes of 438
cessation of 649
diathesis 703
disorder 718
severe 222
Bleomycin 320
Block feeding 675
Blood 628, 766
and blood products 525t
borne transmission 387
changes 104t
in cellular composition of 83t
collection of 38
conservation technique 531
culture 197
gases, implications for 318
glucose monitoring 264
group incompatibility 194
hypercoagulability of 779
hypercoagulable state of 325
products 766
therapy 762
transfusion 6, 282, 287, 766, 767
Blood coagulation factors 105
changes in 105t
Blood loss 644
estimation of 764, 765t
large amount of 646
Blood pressure 233, 234f, 235, 240, 331, 398, 400, 628, 754, 756, 757f
control of 304, 412
apparatus 233f
method 241
reduces 762
systolic 296, 756 756
Blood sugar
level 421
postprandial 106
raised postprandial 258
Blood urea 759
nitrogen 235, 759
Blood volume 82, 400
loss of 644
Bloody nipple discharge 675
Blunt trauma 439
B-lynch suture 648, 649f
Body cavity, formation of 77
Body fluids 715
Body mass index 260, 349
elevated 303
Boerhaave syndrome 99
Bone marrow 282
micronormoblastic reaction 286
transplant 287
Bone morphogenetic protein 74
activity of 74
Bony pelvis 44, 44t
classification of 44t
Bowel care 632
Bowel injury 196f
Brachial plexus injury 607, 708
Bradycardia 154, 590, 754, 776
Brain injury 697
classic patterns of 698t
neurologic markers of 700
Brain iron concentrations 277
Brain natriuretic peptide 105
Brass V drape 731f
Breast 81, 348, 630, 671
care 632
conserving surgery 360
crawl 686
emptying 674
engorgement 631, 671, 711, 711f
examination of 92
infections 673
lump, differential diagnosis of 360b
mass, evaluation of 360
support garment 674
tumor 332
Breast abscess 667, 673, 674f
risk of 360
Breast cancer
early stage 361fc
late stage 361fc
pregnancy after 362
pregnancy-associated 359
Breast milk
and colostrum, composition of 630t
jaundice 675
Breastfeeding 264, 321, 359, 368, 371, 454, 632
advantages of 676
care 633
contraindications for 631
preparation for 631
preterm 678
techniques 676
Breath holding spells 274
Breathing 436, 622, 756, 774
Breathlessness 394
Breech and transverse lie, diagnosis of 500t
Breech delivery, spontaneous 559
Breech extraction 559
partial 559
Breech presentation 176f, 501b, 562
Broad ligament, anterior part of 40
Bromocriptine 253, 547
Bronchiectasis 323
Bronchopneumonia 395
Bronchoscopy 320
Brow presentation 566, 566f
Brown adipose tissue 682
Budd-Chiari syndrome 303, 417
Bullous lesions 337
Bullous pemphigoid 338
Buprenorphine 448
Buttonhole tear 638
Cabergoline 547
Calcineurin inhibitors 296
Calcium 239, 296
binding tendency of 764
channel blockers 238, 506
chloride 779
metabolism 107, 108t
supplements 94
Campylobacter fetus 451
Cancer 356
management of 356, 358t
Candida albicans 671
Candidiasis 375
Cannabis 342
Capillary hemangiomas 76
Capillary refill time 760
Captopril 237
Caput succedaneum 705, 705f, 711, 711f
Carbamazepine 329
Carbetocin 644
Carbohydrate 82
metabolism 105, 258
Carboprost, dosage of 645
Carboxyhemoglobinemia 279
Carcinoma ovary 28
Cardiac arrest 437, 624, 772
in-hospital 776
Cardiac arrhythmia 758
Cardiac disease 244, 245b, 771
Cardiac disorders 256
Cardiac evaluation 235, 700
Cardiac failure 269, 270
Cardiac lesions 252t
Cardiac malformations 177f, 178
rate of 176
Cardiac markers 105
Cardiac organs 176
Cardiac outflow tracts 144
Cardiac output 85, 771
reduced 254
Cardiac rhythm 775f
abnormalities of 754
Cardiac situs 144
Cardiac systole, peak velocity during 167
Cardiac transplantation 256
Cardiac valve surgery 256
Cardiff method 158
Cardiff's chart 158f
Cardinal ligaments 659f
Cardiomyopathy 252, 283, 287
Cardiopulmonary adaptation 682
Cardiopulmonary blood flow 773
Cardiopulmonary resuscitation 437, 744, 772, 777
Cardiorespiratory diseases 485
Cardiotocograph trace features 574t
Cardiotocography 27, 490, 492, 573, 579, 580
components of 590
continuous 438, 573
role of 487
Cardiovascular anomalies 68
Cardiovascular changes 83f, 435
Cardiovascular system 83, 85, 92
development of 76
Carneous mole 196
Carnett's sign 431
Carpal tunnel syndrome 102, 336
Casirivimab 395
Cataracts 68
Category B medication 261
Cauda equina syndrome 624
Caudal dysgenesis 72
Caudal regression sequence 72
Cavum septum pellucidum 142f
Cefotaxime 323, 667
Ceftriaxone 323
Celiac disease 267, 306
adhesion molecules 57
culture artifact 116
division 54
fail 280
free deoxyribonucleic acid 135, 186, 188f, 461, 495
salvage 532
size of 57
Central nervous system 74, 87, 222, 253, 327, 384
effects on 274
infections 327
Central pontine myelinolysis 304
Central venous pressure 757f, 758, 762, 768
Cephalhematoma 712f
Cephalic version, external 501
Cephalocele 75
Cephalohematoma 705, 706f, 712
Cephalopelvic disproportion 353, 577, 588, 588t
borderline 596
Cephalosporins 323, 390, 667
Cerclage, abdominal 201
Cerebellar diameter 144
Cerebral aneurysm 610
Cerebral artery, middle 162, 163f, 167, 490
Cerebral palsy 515
Cerebral tumors 327, 332
clinical features 332
imaging status 332
laboratory findings 332
Cerebral venous thrombosis 283, 327, 331
Cerebral ventricles 144
Cerebroplacental ratio 168, 490
Cerebrospinal fluid 75, 332, 386, 718
Cerebrovascular disease 405
Cerebrovascular disorders 327, 330
Certolizumab 313
conization 362
dilatation 618
dystocia 353
encerclage 200
index 200
insufficiency, signs of 200
smears, abnormal 362
status 581
Cervical cancer 362
diagnostic evaluation of 362
management of 362, 363fc
screening 28
severe hemorrhage in 5
treatment of 7
Cervical incompetence 194, 199
complications 201
contraindications 201
diagnosis 200
etiology of 200, 200t
management of 200
pathogenesis 200
Cervical length 504
measurement 462
Cervix 40, 81, 629
effacement of 578
evaluation of 578
funneling of 504f
length of 504f
Cesarean delivery 405, 490
high incidence of 610
indications of 610
surgical techniques for 612
uterine incisions for 613f
Cesarean hysterectomy
specimen 532f
technique of 531
Cesarean radical hysterectomy 363
Cesarean scar 529
pregnancy 529
Cesarean section 201, 247, 322, 372, 454, 492, 521, 562, 585, 609, 617
anesthesia for 611
complications of 588
consent for 611
epidemiology of 610
indications of 611t
packs 776
surgical techniques 614
Chagas disease 387
Chelation therapy 282, 287
Chemical pleurodesis 320
Chemoprophylaxis 218
Chemotherapy 219, 357, 361, 365
administration of 357
drugs, dose of 357
indications of 219, 220t
Cherney incision 612
Chest compressions 689, 691, 774f
pain 283, 394, 768
acute left-sided 779
syndrome, acute 281283
X-ray of 216f
Chicken pox 123
Chlamydia trachomatis 385
Chloasma 102
Chlorpromazine 304
Chlorpropamide 426
Cholangitis 388
Cholecystectomy 288
Cholecystitis 281, 306
Cholelithiasis 281, 287, 348
Cholestasis 227, 302t
Cholestatic hepatosis 409
Chordin 74
Chorioamnionitis 387, 484
Chorioangioma 480
Choriocarcinoma 215, 215f, 332, 337
histology 216f
Chorionic sac 459
Chorionic villus sampling 135, 149, 151, 152, 154, 186, 282, 285, 297
advantages of 152
disadvantages of 152
gestational age 151
techniques 151
Chorionicity 458, 458t
Choroid plexus cyst 144, 145, 146f
Chromatin 114
Chromosomal aberrations 133, 174
Chromosomal abnormalities 67, 119, 123, 128, 129, 153, 174f
Chromosomal anomalies 198
Chromosomal defect 66
Chromosomal disorders 114, 118
Chromosomal markers 144
Chromosomal microarray 117, 118, 120, 124
Chromosomal mosaicism 116
Chromosomal theory 66
Chromosomal translocation 194
Chromosome 53, 113, 114f
analysis 150
extra set of 118
ploidy status, determination of 188f
segment of 114
Chronic disease, anemia of 288
Chronic hypertension, investigations for 235t
Chronic inflammatory disease 305
Chronic medical disorders 228
Chronic obstructive pulmonary disease 237
Churg-Strauss syndrome 315
Circumvallate placenta 479
Cirrhosis 287, 418
Cisterna magna 142f, 144
Civil registration system 726
Clamping upper pedicles 657f
Clarithromycin 305, 323
Classical cesarean section 654f
Classical uterine
incision 532f
scar 585
Clavicle 707
Clavicular fracture 607, 707, 707f
Cleft palate 117
Clitoris 37
Cloacal exstrophy 78
Clogged milk ducts 672
Clonidine 238
Clostridium 387
welchii 547
Cloxacillin 674
Clubfoot 716f
Clubfoot-congenital talipes equinovarus 716
Coagulation disorders 642
Coagulation profile 197, 778
Coagulopathy 304
Cocaine 342
Coccygeus muscles 41
Coenzymes 350
Cognitive behavioral therapy 344
Cognitive performance, impaired 274
Collagen vascular diseases 235, 295, 337
Collapse, postpartum 522
Colloid 764, 765t
properties of 765t
Colonoscopy 305
Color Doppler 165, 166, 171f
assisted ductus venosus 171f
examination 172
ultrasound 540f
Colposcopic biopsy 362
Columnar epithelium dips 40
Combined oral contraceptives 219, 240, 283
Common bacterial infections 384t
Communication 10, 16, 17
barriers of 14, 14t, 14b
categories of 12t
formal 13
informal 13
methods of 12
nonverbal 12, 13t
one-way 12t
physical nonverbal 12
skills 11
social behavior change 14
two-way 12t
verbal 13t
Community acquired pneumonia 322
Complete blood count 68, 331, 401, 411, 665, 756, 778
products of 193f
types of 487
Condom 454
catheter 646
Condylomata acuminate grows 336
Congenital adrenal hyperplasia, types of 715
Congenital anomalies 463, 684
higher incidence of 319
incidence of 349
Congenital high airway obstruction syndrome 475
Congenital malformation 66t, 329, 522
higher risk of 124
severe 703
Congestive cardiac failure 251, 267, 404, 718
Congestive heart failure 763, 764
Congo red dot test 403
Conjoint twins 464, 464f
Connective tissue diseases 255
Constipation 100, 305
etiology 100
treatment 100
Contact dermatitis 338, 712, 712f
Continuous fetal monitoring 602
Continuous intrapartum fetal monitoring 473
Continuous positive airway pressure 745, 745f
Contraception 240, 240t, 248, 264, 372, 633
counseling 303
field of 7
Contraceptive advice 633
Contracted pelvis 564
Contraction stress test 157, 160, 262
advantages of 161
disadvantages of 161
Convulsive disorder 406
Cooley's anemia 287
Coombs test, indirect 495
Cooper's ligament 674
Cord 227, 483t
abnormality of 478, 542
blood glucose evaluation 713
clamping, delayed 684
complications 522
entanglement 464f
hematoma 154, 543, 543f
abdominal 144
abnormalities 482
length, antenatal determination of 482
round neck 564
number of 144
thrombosis 496
Cordocentesis 135, 152, 476
complications of 154
Coronary artery disease 255, 348
Coronavirus disease 2019 (COVID-19) 201, 323, 393, 455, 665, 756
infection 396
moderate 395
severe 395
pandemic 28, 583, 723
risk markers in 394t
RT-PCR 583
vaccination against 396
vaccine 34
Corpus callosum, agenesis of 75
Cortical necrosis, acute 292
Cortical reaction 54, 55
Corticosteroids 314, 505, 506, 513
use of 508
Cortisol 259
production of 258
Cosmetic distress 335
Costochondral junction 546
Cotrimoxazole 371
Cotrimoxazole preventive therapy 372
Cough 319
pain test 430
Couvelaire uterus 526f
Cow's milk 630t
disadvantages of 631
Cradle cap 713
Cranial fractures 708
Cranial nerves, disorders of 327
Cranial neuropore, closure of 74
Cranial ultrasound 700
Craniofacial defects 76
C-reactive protein 235, 305, 322, 545
levels of 348
Cri du chat syndrome 68
Crichton's method 572
Crohn disease 305
Crown-rump length 76, 91, 129, 130f
Cryoprecipitate 644, 767
Crystalloids 765t
fluid 764
properties of 765t
Culdocentesis 205
Cushing syndrome 235
Cutaneous lupus erythematosus 310f
Cyanosis 715, 715f
Cyanotic heart disease 244
complex 703
Cyclooxygenase 313
Cyclophosphamide 312, 314, 315, 317
Cyclosporine 303, 316, 317
Cylindrical helix 482
Cyst adenoid malformation 476
Cystic fibrosis 323
Cytokines 57, 504
Cytomegalovirus 123, 194, 302, 381, 384, 389, 414, 542, 678
infection 452
Dactylitis 281
Dalteparin 230
Dandy-Walker malformation 75
Decidual bleeding 523
Deep tendon reflexes 708
Deep transverse arrest 557
Deep vein thrombosis 283, 304, 336, 522
pregnancy-related 325
risk of 632
Deferasirox 282, 287
Deferiprone 282, 287
Deferoxamine 282, 287
Defibrillation 774
Defibrillator safety management 775
Deflexion, severe degree of 556
in breech, mechanism of 559
of buttocks, mechanism of 559
of head, mechanism of 559
of shoulder, mechanism of 559
timing of 239, 404, 491, 531, 536
Delivery room 684
management 701
Delta hepatitis 415
Dengue 430
virus 383
Deoxyribonucleic acid 53, 113f, 114f, 187f, 189f
analysis 287
determination of fetal 187
direct 150
sequences 113
Depot-medroxy-progesterone acetate 240
Depression 341
Depressive disorder 341t
Dermatological disorders 335
Desferrioxamine 446
Dexamethasone 303, 505
administration of 514
Dextrocardia 177, 177f
Dextroposition 177
Dextrose 304, 444
Diabetes insipidus 475
Diabetes mellitus 158, 201, 258, 259b, 264, 296, 404, 405, 420, 421t, 543, 578
classification 258
global emergency 421f
pregestational 258
type 1 267, 308
type 2 348
uncontrolled 198
Diabetic ketoacidosis 426
Diabetic mother, management of infant of 263t
Diabetic nephropathy 295
Diabetic pregnancy, infant born from 263
Diabetogenic pregnancy 258, 422f
Dialysis 297
Diamorphine 622, 623
Diaphragm 78
Diaphragmatic hernia 78
congenital 476
Diarrhea 717
Diastolic blood pressure 296, 756
Diazepam 444
Dichlorophenolindophenol 287
Dichorionic diamniotic placenta 467f
Dichorionic twins 459f, 542f
Dicloxacillin 674
Dicyclomine 304
Diet 94, 632
DiGeorge syndrome 117
Digestive tract defects 350
Dihydrocodeine 622
Dilation and curettage 204, 205
Dipeptidyl-peptidase 4 262
Diploid 66
Direct obstetric deaths 726
Discharge per vaginum 362
Disseminated intravascular coagulation 302, 411, 518, 522, 524, 525, 545, 653, 668, 745, 756, 767, 768
Diuretics 238, 325, 404
Dizygotic twins 457
Dobutamine 779
Doderlein's bacilli 38
Dolicocephalic head 564
Dolutegravir 368, 369
Domestic violence and abuse 440
Domperidone 304, 676
Dopamine 779
agonists 547
Doppler cerebroplacental ratio 487
Doppler effect 166
Doppler flow indices 167, 167f
Doppler flow velocimetry waveform analysis, abnormal 311
Doppler velocimetry 158, 162, 262, 495
Dorsal mesentery 77
Double marker test 67
Down syndrome 67, 114, 129, 133, 134t, 135t, 150, 186
phenotype features of 67f
prediction of 67
Doxylamine 99
Drip-drop feeding 678f
ionization of 357
of abuse, poisoning of 447
toxicity 771
use of 618
Ductal arch 184, 184f
Ductus venosus 134, 167, 168f, 490, 492
Duodenal atresia 474f, 475
Dysfunctional labor 554
Dysgerminomas 364
Dysmaturity syndrome 684
Dyspareunia 638
Dyspepsia 305, 462
Dysphagia 316
Dysplasia 123
Dyspnea 318, 319
Dysrhythmias 174
Dystocia 555
Dysuria 430
Early amniocentesis 150
Early obstetric warning
score 753f
system, modified 754t
Early pregnancy 259
complications 193
Ebola 384
Ebstein anomaly 254
Echocardiography 245, 756
timing for 175
Echogenic bowel 145, 145f
Echogenic cardiac focus 144
Eclampsia 35, 267, 311, 398, 404, 406, 411, 541, 543, 770
anticonvulsants for 730
management of 746
prevention of 404
vigilance for 405
Ectoderm 74
development 74f
Ectodermal derivatives 74
Ectodermal dysplasia syndromes 155
Ectopia cordis 78
Ectopic hydatidiform mole 215
Ectopic implantation, site of 203f
Ectopic kidney 473
Ectopic mass 205f
Ectopic pregnancy 70, 198, 202, 206fc
clinical features 203
diagnosis 204
differential diagnosis 205
evolution of 202
incidence 202
location of 70
management of 206
methotrexate treatment for 207t
risk factors for 202, 203t
ultrasound features of 205t
Eculizumab, administration of 294
Eczema 336
Edema, severe 296
Edward's syndrome 67, 114, 129, 150, 186
Efavirenz 369
Ehlers-Danlos syndrome 255, 337
Eisenmenger syndrome 247, 254
Ejection fraction 249
Elective cesarean section, indications of 559
Electrical injuries 440
Electrocardiography 689, 692, 756
Electroencephalogram 328, 331
Electrolyte 702
imbalance 305
panel 197
Electronic fetal
heart rate monitoring 577
monitoring 27, 405, 590
Electronic health
informatics, advantages of 26
record, components of 27, 27f
Electronic partograph 575
Elemental iron 276
Elevated cardiac troponin 700
Elevated liver enzymes 239, 413, 747
Embryo, implantation of 53
Embryoblast 69
Embryo-endometrial interaction 57
Embryogenesis, timeline of 65f
Embryonic stem cells 69
Emergency cesarean section 521
risk of 154
Emergency medical service 777
Emergency obstetric care 727, 730, 744
Emerging infectious diseases 455
Emesis, pregnancy unique quantification of 100t
Encephalocele 75
Encephalopathy 294, 304
End-diastolic flow velocity 163f, 167
Endocardial cushion 76
disorders 485
system 84
Endodermal derivatives 77
Endodermal development 77f
Endodermal sinus tumors 364
Endoglin concentrations 402
Endometrial neoplasms 348
Endometritis 387
Endometrium 40, 57
thickness of 40f
Endoscopy 305
field of 7
Endothelial dysfunction 400
Endotoxin mediated injury 294
Endotracheal intubation, indications of 691
Endotracheal tube 774
Enema 568
Energy sources 274
Enoxaparin 230
prophylactic dose of 395
Enterobius vermicularis 380
Enteroviruses 384
Entonox 622
inducing drugs 329
inhibitors 57
linked immunosorbent assay 311
Eosinophilic hyalinization 217f
Epidermal growth factor 57
Epidermal melanocytes, number of 335
Epidermis 74
Epidermolysis bullosa 155
Epidural analgesia 560, 623
Epidural anesthesia 611
Epidural hematoma 707f
Epigastric pain, symptoms of 305
Epigenetic regulations 405
Epilepsy 327, 328, 544
effects of 328
incidence of 327
maternal implications of 328
treatment of 328
Epileptic seizures 327
Epinephrine 693, 779
Episiotomy 605, 607, 635, 636t
collections 667
complications 637
indications 635
late 638
median 636t
mediolateral 636t
postoperative care 637
types of 636
Epithelial ovarian tumors 364
Epithelioid trophoblastic tumor 211, 216, 217f, 223
Epithelium leading, erosion of 306
Epoprostenol 254
Epstein-Bar virus 414
Erb's Duchenne palsy 708, 708f, 713, 713f
Ergometrine 615, 645
use of 247
Erythema multiforme 337, 338
Erythrocytapheresis 282
porphyrin levels 287
sedimentation rate 235, 282, 320
Erythroid hyperplasia 282, 286
Erythromycin 323, 505, 674
Erythropoiesis, augmentation of 287
Escherichia coli 380, 674
Esophageal atresia 474, 474f
Esophageal cancer 57
Estriol 258
Estrogen 98, 111, 335
role of 409
Etanercept 313
Etymology 610
Euploid pregnancy loss, rate of 348
Exacerbations 321
Exercise 237, 261
Exome 114
Exons 113, 120
External cephalic version, complications of 501, 502b
Extracardiac malformations 174
Extracorporeal cardiopulmonary resuscitation 776
Extracranial injuries 705
Extraembryonic mesoderm, formation of 71f
Extramedullary hematopoiesis 287
Extrapulmonary tuberculosis 321
diagnosis of 321
treatment of 321
Face presentation 564
causes of 564
Facial injury 706
Facial lesions 76
Facial nerve injury 708
Facial palsy 709f
Fallopian tube 41, 70, 207f, 657f
ampulla of 53
Falx cerebri 142f
Family planning 727
Fascia of Scarpa's, blunt dissection of 613
Fasciitis, necrotizing 638
Fasting glucose 68
Fasting plasma glucose 421
Fat metabolism 82
Fatty acid 410, 683
Fatty infiltration, evidence of 304
Fatty lever, acute 292, 293, 301, 304, 408, 410, 411b
Fatty metamorphosis, acute 304
Feasible prediction policy 402
Febrile seizures 274
Feet, edema of 325
Femur 708
length 141f
Fentanyl 622
Ferric carboxy maltose, intravenous 276
Fertilization 53, 55f
defects in 56
process of 54
Fetal abdomen 142f
Fetal abnormality 122, 123, 130f
etiology 122, 123
pathophysiology 122
prevention 124
treatment 124
Fetal adaptive immune responses 451
Fetal alcohol syndrome 344
Fetal anatomy
look for in 139
survey 140
Fetal anemia 123, 153, 168, 169f, 522
Fetal aneuploidy 169, 186, 188, 188f
prenatal diagnosis of 186
risk, estimation of 28
Fetal anomalies, assessment of 169
Fetal ascites 496
Fetal asphyxia 561
Fetal assessment 438
Fetal autopsy 229, 544
Fetal biometry 401
Fetal bladder tapping 154
Fetal blood
loss 688
sampling 152, 591, 592
technical aspects of 153t
Fetal bradycardia 688
Fetal brain 259
damage 465
development 267
Fetal cardiac anatomy 170f
Fetal cells
chromosomal analysis of 186
direct analysis of 186
Fetal cephalic presentation 176, 176f
Fetal chromosomal abnormality 540
Fetal circulation 63, 697f
normal 696
Fetal complications 269, 380, 450, 463, 501b
Fetal condition 572
Fetal congenital malformations, diagnosis of 113
Fetal consequences, long-term 463
Fetal crown rump length, measurement of 170
Fetal death 154, 194, 227, 244, 440
etiology of 540
Fetal defects 73t
Fetal defense 379
Fetal demise 442, 466
diagnosis of 539
Fetal development 61
effects on 329
normal process of 122
Fetal diagnosis, invasive tests for 149
Fetal distress 303, 439, 588
consequences of 267
risk factors for 589
Fetal echocardiography 174, 175, 184
advantages of 184f
analysis 592
indications of 174
Fetal face 142f
Fetal fibronectin 504
Fetal fraction, percentage of 135
Fetal gender, evaluation of 459
Fetal genetics 229
Fetal growth 63
and development 62
monitoring 230
ultrasonographic assessment of 236
Fetal growth restriction 118, 158, 167, 267, 287, 303, 319, 384, 387, 400, 410, 463, 485, 490, 492, 542, 684
diagnosis 486
etiology 485
management principles 487
monitoring 487
pathophysiological progression 487
recent advances 491
screening for 486
severe 541f
ultrasonographic biometry 486
Fetal head 561
delivery of 552
expulsion of 552
hyper extended 502
molding of 572t
rotation of 552
Fetal heart 142f, 540f, 562
monitoring 593
screening 175
sound 320, 556
Fetal heart rate 159, 590f592f, 694, 755f
deceleration of 688
management of abnormal 591
mean of 590
monitoring, minimal duration of 159
Fetal hydantoin syndrome 329
Fetal hydrops 153, 475, 495, 540f, 543, 607, 688
Fetal hyperinsulinemia, complications of 259fc
Fetal hypoxia, marker of 167
Fetal infections 154, 388, 450, 540
Fetal inflammation 505f
Fetal inflammatory response syndrome 388
Fetal lungs 476
Fetal macrosomia 323, 349, 354, 588
pathogenesis of 349
risk of 349
Fetal malformations 119, 323, 358
Fetal malposition, effects of 554
Fetal markers 129
Fetal membranes, inflammation of 505f
Fetal metabolism 421
Fetal middle cerebral artery 168f
Fetal monitoring 262, 262t, 438, 760
Fetal morbidity 408
Fetal mortality 408
Fetal movement 476, 590f
count 158, 158f
loss of 439
Fetal neural tube defects 149
Fetal neuroprotection 240
Fetal nutrition 63
Fetal origin 485
anemia of 540
Fetal pancreatic insulin secretion 259
Fetal pelvis 143f
Fetal period 62
Fetal phase 65
Fetal physiology 61, 259, 688
Fetal position 562
Fetal presentation, abnormal 704
Fetal programming 423f
Fetal pulse oximetry 592
Fetal red cells 279
Fetal reduction, selective 461
Fetal renal tract, abnormalities in 472
Fetal scalp
lactate 592
stimulation 592
Fetal screening, biochemical test for 133
Fetal situs 139, 139t
normal 139
Fetal skull 552
transverse section of 141f, 142f
Fetal spinal vertebra 143f
Fetal spine 143f
Fetal stage 61
Fetal status, nonreassuring 439
Fetal structural malformations 230
Fetal surveillance 236, 283, 401, 425, 426
indications of 158
Fetal tachyarrhythmias 497
Fetal tachycardia 591
Fetal therapy 154
Fetal thrombocytopenia, diagnosis of 153
Fetal thrombotic vasculopathy 484
Fetal tissue
biopsy 135, 155
internal 546
Fetal ultrasonography, indications of 95t
Fetal urine 155t
Fetofetal transfusion syndrome 475, 542
Fetomaternal bleed, amount of 546
Fetomaternal organ 478
Fetoscope 155f
Fetoscopic endotracheal occlusion 78
Fetus 542f, 704
and placenta, inspection of 544
exposure of 123
head of 552
papyraceous 467f
sonogram of 473f
Fever 310, 718
causes of 388t
postpartum 387
Fibrinogen, large amounts of 523
Fibroblast growth factor 74
Fibromyoma 194
Fine needle aspiration cytology 360
First-trimester 91, 126, 260, 306
body mass index 267
recurrent pregnancy loss 198
screening 134
Fist percussion test 431
Flexible fiberoptic bronchoscopy 320
Flow velocity waveforms 163f
Flucloxacillin 674
Fludrocortisone 715
Fluid 762
color of 150
management 100t, 405, 702
overload 305
responsiveness, estimation of 762
restriction 324
Fluid resuscitation 762
colloids for 764
end point of 764
Fluid therapy 762
dosing of 764
Flumazenil 444
Fluorescence in situ hybridization 120, 150
Fluoroscopy 320
Focal nodular hyperplasia 417
Folate, neurological deficiency of 306
Foley's catheter 582, 646
Folic acid 288, 330, 371
supplementation 34, 315, 729
Folinic acid regimen 221
Follicle stimulating hormone 298
Folliculitis, infectious 339
Follistatin 74
Food poisoning 447
Foodborne transmission 387
Footling presentation 558f
Forceps 595
contraindications 596
functions of 596
indications 596
parts of 596f
types of 595
Formaldehyde 194
Foul lochia 387
Fracture 707
risk factors for 708
Fragile sites 68
Fragile X syndrome 68
Fragmentation defects 70
Frank breech 558f
Fraternal twins 457
Free androgens, large amount of 348
Free fatty acids 258
Fresh frozen plasma 644, 767
Friedman's curve 569f
Fulcrum 552
Full fetal echocardiography 246
Functional menstrual disorders 198
Fundal grip 562
Fundoscopy 401
Fundus 39
Fungal dermatitis 712
Fungal infections 380
Funipuncture 152
Furosemide 237, 247
Fusion of gametes 54
Gadolinium contrast 356
Gadolinium-enhanced magnetic resonance angiography 235
Galactagogues, role of 676
Galactocele 631, 672
management 673
ultrasonography 673f
Galactokinesis 630
Galactopoiesis 630
Galactosialidosis 496
Galen malformations 169
Gallbladder 141, 142f
disease 306
Gallium scans 432
Gametes, abnormal 68
Gamma-glutamyl transferase 302, 410
Gardnerella vaginalis 504
Gas exchange, impaired 697
Gaskin's maneuver 606, 607f
Gastric peristalsis 305
Gastric pressure 305
Gastroenteritis 305
Gastroesophageal reflux 304, 322
and heartburn 100
disease 319
Gastroesophageal rupture 99
Gastrointestinal conditions 305, 412, 473
pregnancy-specific 304
Gastrointestinal disease 301
Gastrointestinal tract 84, 221, 628
anatomy of 304
physiology of 304
Gastroschisis 78, 473
risk of 350
Gastroscopy 305
Gaucher disease 496
Gel electrophoresis 282
General anesthesia 625
Genes 113, 119, 405
therapy 287
Genetic abnormalities 229
Genetic counseling 230, 282, 288
post-test 188
Genetic disorder 114
suspicion of 230
types of 114, 115fc
Genetic information 191
Genetic syndromes 473
Genetic tests 152, 230, 282
types of 119
Genital tract disorders 518
Genitalia, female external 37f
Genitourinary system 430
Genitourinary tract conditions 412
Genome 113
editing techniques 288
Genomic disorders 117
Genotype 68, 114
Germ cell tumors 364
Gestation trophoblastic disease 325
Gestation, length of 71
Gestational ages 471t
large for 349, 420, 422
parameter of 470f
small for 167, 275, 294, 414, 490, 492, 714
Gestational anemia 275
Gestational carcinoma 211
Gestational choriocarcinoma 215
Gestational diabetes mellitus 105, 117, 119, 258, 267, 349, 350, 420, 475
diagnosis of 422
epidemiology 420
management of 424
screening tests for 106t
Gestational epilepsy 328
Gestational hypertension 398, 404
Gestational pemphigoid 337
Gestational transient thyrotoxicosis 269, 270
Gestational trophoblastic disease 198, 210, 217, 223, 269
Gestational trophoblastic neoplasia 211, 216f, 219, 220, 220t, 222, 222t
diagnosis of 219
high-risk 221
low risk 221
postmolar 219
Gestosis score 398, 402t, 420
enigma of 405
significance of 402
Glasgow coma scale 745, 752, 758, 758t
Glibenclamide 261
Globin chain
composition 284
synthesis, quantitative disorders of 279
Glomerular disease 293
Glomerular endotheliosis 293
Glomerular filtration rate 84, 291
Glomerulonephritis 295
Glucocorticoids, administration of 294
Glucometer 260f
Glucose 63
metabolism 63, 422f
monitoring, frequency of 759
transport 63
Glucose-6-phosphate dehydrogenase deficiency 390
Glutamic acid
beta-chain substitution of 284
lysine for 284
Gluten sensitive enteropathy 306
Glyburide therapy 426
Glycemia monitoring 264, 759
Glycemic control 261
Glycerol trinitrate 501
Glycoprotein 311
Glycosylated fibronectin 403
Golimumab 313
Gonadal mosaicism 116
Gonadotropins 348
Gonorrhea 375
Gram-negative enteric bacilli 281
Grand multipara 779
Granular cytoplasmic bodies 286
Granulocyte colony stimulating factors 357
Granulomatosis 315
Granulomatous inflammatory disease, chronic 305
Graves' disease 268, 269, 271, 313, 314
risk of 338
Graves' hyperthyroidism 269
Gravid uterus 301
Greater vestibular glands 38
Growth 61
centile chart of fetal demise 541f
factor beta, transforming 110
factors 357
Guillain-Barré syndrome 316, 327
Gynecoid 45
H1N1 virus 323, 380
Haemophilus influenza 281, 323, 380
Hair changes 336
Haploid chromosomes 113
Hartmann's sign 71
Hashimoto thyroiditis 314
and neck masses 475
circumference 486
deflexion of 556
Headache 304, 623
Health and well-being, promoters of 740
Health care, communication in 15
Health communication, applications of 14
Health impacts, severe 266
Health management and information system 747
Health system interventions 96
Healthcare personnel 682
violence 48t
Healthcare seeking behavior 721
Healthcare system 10
axis 144
chambers of 178f
connections of 175t
defects, congenital 117, 254, 350, 710
disease 243, 244t, 245, 246t, 544
functional class of 246
failure 270
function 180
rate 331, 754, 756
septum 76
size 178
valves of 183f
Heat loss, prevention of 684
Heavy metal absorption 274
Hectic fevers 664
Heinz bodies 286
Helicobacter pylori 305
Hellin-Zeleny's law 457
HELLP syndrome 239, 293, 301, 303, 408, 410, 413, 525
Hemangioendothelioma 496
Hemangiomas 336
Hematological changes 82, 104, 435
Hematoma 523, 667
Hematopoiesis, stage of 287
Hematopoietic stem cells 287
Hematuria 292, 310, 756
Hemoconcentration, severe 411
Hemodynamic adaptation 349
Hemodynamic status 204t
Hemoglobin 104, 279, 403, 531
Bart disease 286f
C 284
concentration 762
deficit, basis of 276
disorders 279
E 284
electrophoresis 286
report, normal 287f
gamma genes of 122
level, normal 273t
structural variants of 279
synthesis, inherited disorders of 279
Hemoglobinopathy 153, 279, 284
classification of 279
clinical features 280
pathophysiology 280
unstable 280
Hemoglobinuria 756, 768
Hemogram 433
Hemolysis 239, 293, 302t, 411, 413, 747
signs of 767
Hemolytic crises 281
Hemolytic reaction, delayed 283
Hemolytic uremic syndrome 292
Hemoperitoneum 207f
Hemopoietic cell transplantation 282
Hemorrhage 223f, 255, 430, 438, 546f, 746, 770
accidental 522
antepartum 292, 462, 518, 527, 694, 743, 763, 770
causes of 518, 518t
epidural 706
fetomaternal 154, 496
intracerebral 328
intracranial 771
intraventricular 707
mild 525
obstetric, causes of 770
postpartum 267, 292, 349, 405, 522, 547, 607, 608, 641, 644t, 645fc, 646, 665, 727, 743, 756, 763, 770
causes of 642
etiology of 647f
preventing 405
severe 675
surgical management of 645
subarachnoid 328, 331, 707
causes of 331
subchorionic 194
subgaleal 706
unavoidable 518
Hemorrhoids 101, 101f, 306
develop 306
etiology 101
symptoms 101
treatment 101
veins develop 336
Hemostasis, special care for 654
Heparin, unfractionated 252
Hepatic adenoma 417
Hepatic dysfunction 411, 412
Hepatic failure 445
Hepatic system 408
Hepatitis 382, 414, 415f
A 95, 414
prevention of 414
virus 414
B 89, 95, 408, 414, 453
acute 415
surface antigen 149
C 89, 408, 414, 415
virus 94, 149
D 408, 414, 415
E 414, 416
infective 408
viral serology 411
viruses 413t
Hepatobiliary iminodiacetic acid 432
Hepatobiliary system 430
Hepatocellular carcinoma 418
Hepatocytes 259, 304
Hepatolenticular degeneration 416
Hereditary anemias 279
Hereditary renal disease 295
Hereditary thrombophilias 541, 543
Heritable thoracic aortic disease 249
Hernia, inguinal 716
Herpes gestationis 337
Herpes simplex 194, 452, 671, 678
virus 375, 381
infections 452
Herpes zoster 671, 678
lesions 671
Heterozygosity, absence of 120
High dependency unit 411
High fetal middle cerebral artery 169f
Hirsutisim 336
Home uterine activity monitoring 504
Homozygous 211, 280, 410
Hormonal abnormalities 339
Hormonal therapy 357
Hormones 677
enzymes 350
Human attitude 8
Human chorionic gonadotropin 70, 84, 85f, 98, 109, 110f, 134, 204, 206, 211, 217, 220, 224, 266, 304, 715
abnormal 198
Human chorionic thyrotropin 266
Human chromosome
packaging of 113f
structure of 113f
Human deficiency virus control 727
Human genome project 113
Human growth hormone 259
Human immunodeficiency virus 89, 124, 149, 194, 321, 323, 367, 370, 382, 454, 678
infection 367, 369, 370
laboratory diagnosis of 368
low prevalence of 368
management of 372
mother-to-child transmission of 737
prevalence 367
transmission 454
types of 367
Human leukocyte antigen 270
Human milk 630t, 674
Human papilloma virus 375
exacerbates 336
Human placental
alpha macroglobulin 504
lactogen 105, 110, 259, 486
lipids 335
Humerus, fracture of 607
Hydatidiform mole 211, 337, 466
complete 211, 212, 214, 214f, 215t
diagnosis of 217
genetics of 211
management of 218
partial 118, 211, 212f, 214, 215t
Hydatidiform pregnancy, benign 325
Hydralazine 238, 296, 310
Hydramnios 324, 461
Hydration 474
Hydrocortisone 357, 715
Hydronephrosis 473
Hydrops 476, 495f
fetalis 475f
Hydroquinones 335
Hydroureter 473
Hydroxychloroquine sulfate 310
Hymen 38
Hyperactivity disorder 68
Hyperbilirubinemia, congenital 302t
Hyperechoic bowel 144
Hyperemesis gravidarum 98, 269, 270, 304, 413
Hypergalactia 675
Hyperglycemia 260, 420
clinical clues for 421
Hyperintense heterogeneous placenta 530f
Hyperkalemia 294, 297, 715, 778
Hyperlactation 675
Hypermetabolic state 270
Hyperosmolar glucose 206
Hyperprolactinemia 198
Hypertension 194, 233, 296, 401, 523, 754, 756
chronic 158, 233236, 240t, 398, 405, 485, 541, 543
control of 237
degree of 237
essential 234
management of 296
masked effect 234
mild 233
pathway for 754
portal 418
pregnancy 158, 292, 303, 461
resistant 237
secondary causes of chronic 234t
severe 233
chronic 239
transient 234, 235
treatment of chronic 236
Hypertensive disorders 158, 398, 420, 485, 541, 543, 547, 743
clinical classification of 399
diagnosis 400
incidence of 398
spectrum of 411
Hyperthyroidism 268, 270
causes of 268
clinical features of 268
effects of 267, 269
essential of diagnosis 268
manifestations of 269
subclinical 268, 270
temporary 270
treatment of 269
Hypertonicity 344
Hypertrophic cardiomyopathy 253
Hypertrophic obstructive cardiomyopathy 253
Hyperviscosity 684
Hypocalcemia 297, 684, 778
Hypoglycemia 683, 684
clinical 264
prevention of neonatal 264
Hypokalemia 778
Hyponatremia 304, 715
Hypoplastic kidney 473
Hypoplastic umbilical artery 482
Hypoproteinemia 296
Hypospadias 329, 718
Hypotension 754
management of severe 746
severe 623, 624
Hypothalamic receptors, regulation of 348
Hypothalamic-pituitary-ovarian axis 348
Hypothermia 683, 684, 778
state 270
treatment of 268
Hypothyroidism 267, 405
causes of 267
complicated pregnancy 271
consequences of 267
diagnostic criteria of 267
encountered, types of 267
management of 266, 267
permanent 270
prevalence of 266
risk factors for 266
severity of 267
temporary 270
Hypotonic saline 474
Hypovolemia 591, 778
acute maternal 473
Hypovolemic shock 764
Hypoxemia, progressive 158
Hypoxia 154, 778
chronic 244
prevent 778
Hypoxic ischemic encephalopathy
classification of 700t
risk factor for 697
treatment of 701
Hysterectomy 215f, 219f, 223f, 647
Hysterotomy 197
resuscitative 438
Ichthyotic disorders 155
Icterus gravidarum 409
Iliac crest, right 306
Iliac vessels, external 171
Iliopsoas test 430
Illness, self-limiting 332
Imatinib 358
Imdevimab 395
Imipenem 323
complexes 485
fetal hydrops 495
diagnosis 495
management 495
status, impaired 274
system 104
changes 450
Immunization 95, 451, 633
Immunoglobulin 302, 309
G 268, 311, 667
Immunologic techniques 389
Immunology 399
Immunosuppressive agents 296
Impetigo herpetiformis 337
Implantation failure 58
Imprinting disorders 117
In situ publication bias 25
In utero hypoxia 688
In vitro fertilization 212
embryos 69
Inadequate placental perfusion 399
Indomethacin 297, 473, 476
Infant feeding policy 632
Infections 194, 227, 336, 378, 379t, 388, 504, 637
categories of 379t
chronic 485
congenital 388
control policy 615
effects of 388
prevention of 390
types of 389
Infectious disease screening 89
Infective endocarditis 247
prevention of 247t
Infertility 28, 267, 348
Inflammation, intensity of 484
Inflammatory bowel disease 305, 315
Infliximab 313
Influenza 323
A 380
vaccination 323
vaccine 95
virus 414
Inherited anemias 153
Inotropic agent 779
Insect-borne transmission 387
Instrument, parts of 595, 599
Instrumental birth, reduced 737
Instrumental delivery
frequency of 610
high 596
incidence of 595
Instrumental vaginal delivery 595
classification of 596t
complications 598
Insulin 6, 426
binding of 259
free 259
resistance 422f
obesity related 349
secretion 258
therapy 261, 425
Insulin-like growth factor 76
binding protein, levels of 348
Intensive care unit 349, 411, 743745, 745f, 747, 749, 756, 760, 766
Intensive critical care medicine, principles of 749
Intensive multi-modality therapy 222
Interglandular tissue 40
Interleukin 348
Internal capsule, posterior limb of 700
Internal iliac artery 42, 648f
anterior division of 43f
branches of 43f
ligation 532
ligation of 649f
Interstitial nephritis 295
Intertwin membrane thickness 460
Interventional chest procedures 319
Intestine 430
Intimate partner violence 89, 437
Intra-amniotic infections 505
Intracardiac echogenic focus 146f
Intracranial injuries 706, 706f
Intracranial translucency 130
Intractable heart failure, acute 247
Intraembryonic mesoderm
formation of 72f
migration of 73f
Intrapartum analgesia, reduced 737
Intrapartum care 240, 396, 476, 586
routine 567
Intrapartum complication 368, 463
Intrapartum fetal heart rate monitoring 573
methods of 573fc
Intrapartum fetal monitoring 405
Intrapartum loss 230
Intrapartum management 330, 404, 426, 507, 593
Intrapartum periods, management of 418
Intrapartum surveillance, methods of 589
Intrapartum tests 567
Intrathoracic masses 475
Intrauterine death 292
late 118
Intrauterine device 240, 303
failure 194
Intrauterine fetal death 230, 545, 578, 583
causes for 542
Intrauterine fetal demise 267, 539
evaluation of 544
Intrauterine gestational sac 126f
Intrauterine growth
restriction 227, 283, 442, 522, 524, 540, 578, 694, 713, 714f
retardation 384
Intrauterine infection 504
stages of 505f
Intrauterine system 240
Intrauterine transfusion 476
Introns 113
Invasive disease 362
early stage 362
Invasive mole 215
Invasive monitoring, methods of 644
Invasive squamous cell 217f
Inverted nipple 631
Iodine insufficiency, moderate-to-severe 266
Iron 633
enhancers of 276
inhibitors of 276
chelators 282, 287
deficiency 274, 286
anemia 274, 287, 288
consequences of 274
deposition 286
indices 286
intoxication, acute 446
metabolism 82
complex therapy 276
intravenous 276
supplementation 94, 729
Ischemia 688
Ischemic heart disease 255, 405
Ischemic stroke 327, 330
Ischial spine 624
Isochromosome 116
Isoniazid 321
prophylaxis 321
indications of 321t
Isotonic crystalloid solution 768
Isotonic saline 474
Jacobs syndrome 186
Jacquemier's maneuver 606, 607f
Janani Shishu Suraksha Karyakram 729
Janani Suraksha Yojana 729
Janus kinase inhibitors 313
Japanese encephalitis 384
Jaundice 91, 287, 302, 302t, 430, 714, 714f
causes of 302t
physiological 714
recurrent 409
Jehovah's witnesses 532
Joel-Cohen incision 612
Joint replacement 312
Jugular venous pressure 325
Kangaroo mother care 676, 684
Karyotype, abnormal 542
Kasabach Merritt syndrome 496
Kayser-Fleischer ring 416
Kerr incision 613
Ketones 258, 259
Ketonuria, quantification of 414
Ketosis, signs of 414
Kidney 235, 281, 473, 496
biopsy 294
damage 473
disease 405
chronic 294, 295, 298
donors 298
dysfunction, stage of 295
function 291
assessment of 296
measurement of 293
injury, postrenal acute 293
Kielland forceps 598, 598f
Klebsiella 380
Kleihauer test 546
Kleihauer-Betke test 437
Klinefelter syndrome 67, 133, 150, 186
Klumpke's palsy 708
Labetalol 237, 296
majora 37
minora 37
Labor 550, 555
active management of 573
analgesia 621
clinical correlation 551
clinical course of 563
complications 743
course of 556
elective induction of 583
first stage of 586
general management of 247
induction of 405, 537, 577, 579, 580t, 582, 582t
initiation of 550fc
malpresentations in 558
management of 565
first stage of 568
fourth stage of 574
second stage of 573
mechanism of 553, 554, 556, 559, 565
poor progress of 586
preparation for 567
progress of 568, 569, 572
prolonged second stage of 588t
room nurse 371
second stage of 586, 588
stage of 560
third stage of 353, 522, 574, 643
Labor and delivery 246, 319, 353
management of 283
Lacerations 704, 705
Lactate dehydrogenase 401, 403
Lactation 305, 547, 630
management 454
mastitis 387
physiology of 630
preparation for 631
support 747
suppression of 631
Lactation failure 675, 677fc
management of 676
secondary 675
Lactogenesis 630
Lactogenic diet 677
Lamivudine 368, 369
Language impairment, risk of 264
Laparoscopic surgery 206, 357
Laparoscopy 205
Laparotomy 206, 668
Large-bore cannula 778
Laryngeal mask airway 436
Laryngeal nerve injury 709
Laryngeal papilloma 336
Lassa fever 384
Latching pain 671
Late pregnancy
complications 499
loss 229t
maternal evaluation for 228t
Laxatives 639
Lead poisoning 288, 446
chronic 447
Leaving placenta in situ 532
Lecithin 150
Leflunomide 312
Left tubal ectopic pregnancy 207f
Left uterine displacement 772, 773f
Left ventricular ejection fraction 248
Left ventricular failure 398
Left ventricular outflow tract 140, 175, 177, 180, 180f
Leopald's maneuver 93f
Leprosy 337
Leptin 98
Leptospirosis 385
Lethal multiple pterygium 496
Leukocytes 83, 104
Leukopenia 310
Levator ani 41
muscle 38, 552
Levetiracetam 330, 702
Levonorgestrel 240
Levothyroxine sodium 267
Leydig cell testosterone secretion 348
Life-threatening postpartum hemorrhage 767
Ligament 655
broad 657f
ligation of 660
portion of broad 657f
Lignocaine 779
defects 350
reduction 123, 123f
shortening 144
Linea nigra 102f
Lipid emulsion, intravenous 779
Lipid metabolism 106
changes in 106t
Lipid profile 68
Lipid solubility 357, 678
Lipolysis 683
Liquid based cytology 28
Liquid chromatography 282
Liquor amnii 572
Listeria monocytogenes 451
Listeriosis 388
monocytogenes 542
Lithium 267, 475
Litzmann obliquity 551
anatomy of 301
biopsy 304, 410, 411
conditions 301
enzymes 68, 401
functions of 301
hematoma 304
metastases 222
oxidize ketones 259
parameters 665
physiology of 301
spleen scans 432
test 235
volume 78
Liver disease 301, 302, 408
chronic 416
classification of 409t
end-stage 416
nonpregnancy-related 409
pregnancy-related 409
Liver disorders
classification of 408
evaluation of 418
Liver function test 106, 107t, 197, 218, 302, 303, 310, 331, 384, 403, 408, 409, 433, 443, 756, 778
abnormal 408
physiological changes in 408t
Liver transplant 418
recipient 303
Local anesthesia 624
Lochia 629
alba 629
rubra 629
serosa 629
Long forgotten disease 453
Loop diuretics 237
Loss of weight 628
Lovset's maneuver 561, 562f
Low birth weight babies 678, 683
Low end-tidal carbon dioxide 780
Low intelligence quotient 267
Low molecular weight heparin 252, 283, 296, 312, 325, 395, 491
Low platelet count 747
Low serum alpha-fetoprotein 133
Lower esophageal
pressure 304
sphincter tone, reduced 305
Lower segment cesarean section 197, 230, 384, 577, 580, 582, 586f, 718
Lower urinary tract 654
obstruction 154, 473
Lower uterine segment 613
cesarean section 353
measurement of 619
Lump, abdominal 430
diseases, infiltrative 324, 324t
injury, acute 320, 768
tumor 332
Lung-to-head ratio 78
Lupus anticoagulant 199, 311
Lupus nephritis 297
Luteal phase defects 198
Luteinizing hormone 298
Lyme disease 386
Lymphadenopathy 310
Lymphatic abnormalities 496
Lymphedema, congenital 496
Lymphocyte abnormalities 270
Lymphocytic hypophysitis 271
Macerated fetus 195f
Mackenrodt's ligaments 40
Macrolide 323, 390
Macrosomia 353, 420, 704
Macular pigmentation 335
Magnesium sulfate 324, 506, 515
role of 240
Magpie trial 35
Maladaptation, risk of 683
Malar rash 310f
Malaria 194, 386
abdominal 430
parasite 411
prevention intermittent 95
prophylaxis 282
Malformation 66, 450, 542
Mallory-Weiss tear 98
Malpresentations 462, 499, 522
diagnosis 499
differential diagnosis 499
investigations 500
management 499
Mammary gland 74
Mammogenesis 630
Manual uterine displacement 437
Manual vacuum aspiration 730
Marfan syndrome 255
Marijuana 342
Marshall burn's technique 560
Mass media method 14
Massive blood transfusion 768
risk of 768
Massive hemoperitoneum 207f
Massive perivillous fibrin deposition 483
Massive transfusion protocol 766
Mastectomy 360
therapeutic equivalence of 360
Mastitis 388, 673, 674f, 711
causes of 673
infectious 673
Maternal adaptations 80
Maternal anatomy uterus 144
Maternal anemia 295
Maternal blood
glucose levels 349
supply, development of 59f
Maternal cancers 190
Maternal cardiac disease 243, 610
effects of 244
Maternal cardiovascular risk 248
classification of 249t
Maternal circulation, glucagon in 259
Maternal cyanotic heart disease 158
Maternal death 405, 726, 727, 733, 734
audit 730
causes of 726
classification of 726
surveillance 734f
Maternal defenses 378
Maternal depression 405
Maternal dietary supplementation 489
Maternal disorders 199
Maternal early warning criteria 751
Maternal human leukocyte antigen 312
Maternal hydration 473, 474
Maternal hyperglycemia 422, 423f
Maternal hyperthyroidism, poorly controlled 158
Maternal hypothyroidism 271
Maternal hypoxemia, severe 254
Maternal infection 123, 199, 388, 450, 451, 678
routes of 387
Maternal injury, risk of 608
Maternal morbidity 583, 762
severe acute 349, 743
Maternal mortality 255, 725
rate 725727
ratio 726, 728t, 729, 738, 743
reduce 731
Maternal nutritional deficiency 123
Maternal obesity 350, 354, 705
Maternal organs 400
Maternal plasma 186, 495
Maternal polycythemia 244
Maternal preeclampsia, screening for 171
Maternal pulmonary disease 610
Maternal serum biochemical markers, abnormal 523
Maternal syndrome 400
Maternal syphilis 374
Maternal trauma 541
Maternal ultrasonography 401
Maternal uterine vasculature 84
Maternal varicella infection 123f
Maternal vascular
diseases 158
malperfusion 483
Mauriceau-Smellie-Veit technique 561f
Maylard incision 612
McDonald's operation 200
McFonald's suture, placement of 201f
McRobert's maneuver 605, 606, 606f, 607
Mean corpuscular hemoglobin 282
concentration 104
Mean corpuscular volume 282
Mechanical ventilation 745f
Meckel Gruber syndrome 473
Meconium aspiration syndrome 349, 683, 684, 710
Meconium passage 688
amniotic fluid 694
liquor 593, 693
Mediastinal adenopathy 321
Medical disorders, prevalence of 610
Medical nutritional therapy 425
Medical simulation technology 27
Medical termination of pregnancy 194
indications of 271
role of 271
Medical therapy, maximal 251
Megacystis 473
microcolon 473
Meiosis 66f
Melanocyte stimulating hormone 335
Melanoma 337
Melena 430
Melisma, exacerbations of 335
Membrane 483t
rupture of
artificial 579, 580
prelabor 463, 721
premature 154, 578, 694
prolonged 524
Memory, impaired 405
Mendelson's syndrome 779
Meningeal sac, herniation of 75
Meningocele 147f
Meningomyelocele 716, 716f
Menstrual irregularities 348
Menstrual losses 275
Menstrual period 71
Menstruation 629
Mental health
impact of 340, 343
issues 340, 341, 345
problem 341, 343
management strategies for 343
Mental retardation 344, 450
genetic cause of 133
Mentzer index 286
Mercury sphygmomanometers 241
Meropenem 323
Mesoderm 75
development 75f
Metabolic acidosis 222, 667, 715
refractory 294
Metabolic adaptation 683
Metabolic control 260
Metabolic disorder 258, 303, 778
Metabolism, inborn errors of 496
Metalloproteinase, tissue inhibitors of 57
Metastatic cerebral tumors 332
Metastatic disease 223
Metastatic tumors 481
Metformin 261, 677
therapy 425
Methadone 448
Methamphetamine 543
Methemoglobinemia 279
Methicillin-resistant Staphylococcus aureus 323, 675
Methimazole 269
Methotrexate 206, 221, 312, 314, 315, 317
therapy 207t, 315
use of 533
Methyldopa 238, 296, 404
Methylene dioxymethamphetamine 342
Methylergometrine 405
Methylprednisolone 357
Metoclopramide 305, 676
Metronidazole 305, 390, 505, 667
Microarray analysis 542
Microinvasive disease 362
Micronized progesterone 462
Microvesicular fatty infiltration 304
Microvesicular steatosis 304
Mid face hypoplasia 344
Midpelvis 44
Midwifery services framework 738
Mifepristone 197
combination of 547
Migraine headache 327
Milia 718
blisters 671, 672
fever 671
fistula 360
insufficiency syndrome, secondary 675
rejection sign 360
stasis 673
Millennium development goals 693, 727
Miller-Dieker syndrome 68
Mineral metabolism 82
Mineralocorticoids 715
Miscarriage 198
rates of 294
recurrent 198, 199t, 417
risk of 135, 244
spontaneous 117
Misoprostol 197, 305, 579, 580, 615
Mitigate violence 48, 49t
Mitochondrial fatty acid oxidation 410
Mitosis 66f
Mitral regurgitation 251
etiologies of 251
Mitral stenosis 248
Mitral valve 180f, 248
Mitral valvotomy, closed 251
Mityvac cup 599f
Mityvac vacuum 599
Mobilization 568
Mode of delivery 405, 497, 676, 705
Molar pregnancy 98, 118, 218f
clinical presentation of 217
Mole-focal hydropic degeneration, partial 214f
Mongolian blue spots 718
Monoamniotic twins 458, 459f, 463, 464f
Monochorionic twin 459f, 460f, 464
complications 172
gestation 475
Monoclonal antibodies 395
Monogenic disorders 116
Mononuclear cells 339
Monosomy X 189
Monotherapy, antihypertensive for 237
Monozygotic twinning 457, 458, 458t, 463
etiology of 460
rate of 457
testing in 190
Mons pubis 37
Mood disorders 340
symptoms of 341
Moro's biceps 708
Moro's reflex 707
Morphine 444
Morphological growth 62
Morphological left atrium 178
Morphological right ventricle 178
maternal 731
neonatal 731
Morula stage embryo 57f
Morulation 69f
Mosaicism 66
Motor vehicle collision 439
Mouth ulcers 306
Mouth-to-mouth breathing 774
Mucolipidoses 496
Mucopolysaccharidoses 496
Mucus, passage of 305
Mucus-secreting tubule, pair of 38
Müllerian anomalies 194
Müllerian defect 194
Multicystic dysplastic kidney, bilateral 472
Multidisciplinary team
approach 288
care 530
involvement of 395
Multifactorial disorders 117
Multifetal gestation
diagnosis of 461
mechanism of 457
Multiorgan failure 222
Multiparity 564
Multiple births, incidence of 457
Multiple café-au-lait spots 337
Multiple gestation 154, 227, 324, 475, 523, 684
Multiple organ dysfunction score 749
Multiple pregnancy 154, 194, 304, 457, 519, 540
complications of 544
incidence 457
screening in 135
testing in 190
Multiple sclerosis 316, 327, 332
Multiple soft markers 146
Multiplex ligation-dependent probe amplification 120
Multisystem disorders 684
Mumps 384
Murphy's sign 430
cells 274
fibers 216f
spasm 316
Musculoskeletal dysplasia 129
Musculoskeletal injuries 441
Musculoskeletal system 87
Music and aroma therapy 622
Myasthenia gravis 313, 332
Mycobacteria 674
Mycobacterium tuberculosis 321, 385, 451
Mycophenolate 314
mofetil 317, 418
Mycoplasma hominis 504
colonization 512
Myeloid leukemia, positive chronic 358
Myelomeningocele 75
Myelosuppression 222
Myocardial infarction
acute 255t
risk of 240
Myoma uterus 194
Myomectomy scar 197
Myometrial scar thickness, role of 583
Myometrium 223f
Myotonic dystrophy 333, 496
N acetyl-P-benzoquinone imine 445f
N-acetylcysteine 444, 445f
Naegele's s obliquity 551
Nail growth 336
Naloxone 444, 448, 693
administration of 444
Narrow palpebral fissures 344
Nasal bone 134
Nasal septal dislocation 706
National AIDS Control Organization guidelines 369
National Center of Health Statistics 720
National Family Health Survey 686
National Health Mission 729
National Infant Feeding Guideline 372
National Institute for Health and Care Excellence 237, 740
National Institutes of Health 514
database 248
National Maternity Benefit Scheme 729
National Medical Commission 28
National Midwifery Training Institute 741
National Partnership for Maternal Safety 745
National Program 368
National Registries 28
National Safe Motherhood 728
National Technical Advisory Group on Immunization 95
Nausea 98, 99, 412f
and vomiting, form of 413
complication 98
examination 99
excessive 461
investigations 99
treatment 99
Navirapine, single dose 368
Navjaat Shishu Suraksha Karyakram 693
Necator americanus 380
Necrotizing enterocolitis 683
risk of 515
Neisseria gonorrheae 384, 512
Neoglucogenic substrate 259
Neonatal abstinence syndrome 344, 345, 448
Neonatal alloimmune thrombocytopenia 153
Neonatal care 263
Neonatal coagulopathy 329
Neonatal complications 244
Neonatal encephalopathy 700
Neonatal hypothyroidism 267
Neonatal infection 388
Neonatal intensive care unit 168
Neonatal iron biology 277
Neonatal mortality 319
Neonatal resuscitation 688
program 689
Neonatal screening 124
Neonatal sepsis 349
Neonatal transport 686
Neonate develops respiratory depression 623
Neonates born 277
Nephrotic syndrome 295
grafting 708
injuries 624, 708
Neu-laxova 496
Neural crest cells 74
Neural tube defects 74, 117, 147, 329
Neurofibromatosis 337
Neurological conditions, classification 327
Neurological disorders 327, 412
Neurological disruption 475
Neuromuscular junction blocker 330
Neuromusculoskeletal problems 633
Neuronal discharge, abnormal 327
Neuronal trauma 697
Neuroplasty 708
Neuroprotective strategies 702
Neutrophil lymphocyte ratio 394
Newborn care corner 684
Newborn mortality 737
Nifedipine 238, 296, 404, 501, 506
Nimesulide 473, 476
bite 671
fissuring of 336
pain 671
Nitric oxide 254
donors 507
inhaled 282
synthesis 349
Nitrous oxide 622
Nonalcoholic hepatitis 418
Non-breastfeeding infants 454
Nonimmune fetal hydrops 118, 227, 495, 496
diagnosis 496
etiology 496
management 497
Noninvasive continuous positive airway pressure 395
Noninvasive peripheral oxygen saturations 756
Noninvasive prenatal testing 186, 187
accuracy of 188, 189t
principle of 187f
Nonnucleoside reverse-transcriptase inhibitors 368
Nonopioid analgesics 622
Nonpersonal violence 47
Nonpharmacologic lifestyle interventions 236
Nonpneumatic antishock garment 731, 732f
Nonreactive nonstress test 160f
Nonretractable prepuce 718
Nonshockable rhythms 775
Nonsteroidal anti-inflammatory drug 246, 282, 305, 310, 321, 615, 622
Nonstress test 157159
advantages of 160
disadvantages of 160
twice weekly 263
Nonsurgical scar 529
Nontraumatic liver rupture 304
Nontubal ectopic pregnancy 206, 208t
Noonan syndrome 255
Noradrenaline 779
Nordic obstetric surveillance study 529
Normal pregnancy, hyperlipidemia of 106
Normal puerperium 628
anatomical changes 629
physiological changes 628
Nuchal arms 502
Nuchal cord 143f
Nuchal fold 144
thickness 144, 145f
Nuchal translucency 130f, 133, 134
levels 297
Nucleic acid 413
Nucleotide 113
polymorphism, single 189f
monitoring of 759
supplementation 371
Nutritional deficiency 485
Nutritional interventions 94
Nystagmus 68
O'lLeary method 648f
Obese pregnant patients 348
Obesity 267, 318, 347, 348, 543
effects of 348
management of 350
paradox 348
postpartum 353t
prevention of 354
Obsessive compulsive disorder 340, 341
Obstetric care 297
Obstetric cholestasis 303, 409, 541, 543
Obstetric deaths, indirect 726
Obstetric emergency 619
Obstetric examination 92
Obstetric formula, terminology for 92t
Obstetric high-dependency unit 745
Obstetric hysterectomy 652, 655f
complications of 652t
decision of 652
indications of 653
technique of 647
Obstetric intensive care unit 745
Obstetric management 444, 546
Obstetric shock 598, 762, 763fc
Obstetric transition 735
Obstetrical care 727
Obstetrical complications 292, 348
Obstetrical emergency 304
Obstetrical neuropathy 633
Obstructed labor 618
Obstructive sleep apnea 348
Obturator test 431
Occipital cortex 557
Occipital frontal circumference 706
Occipitoposterior position, diagnosis of 556
Occult blood 433
Occulta 147
Ocular injuries 706
Oculocutaneous albinism 155
Odon device 602
Oligohydramnios 158, 162f, 287, 311, 472, 475
causes 472
etiology of 472, 472t
incidence 472
pathogenesis 472
sequence 472
Oligomenorrhea 417
Omissions 726
Omphalocele 78
Ondansetron 304
denudation 56f
maturation 54
Operations, types of 595
Operative deliveries, risk of 420
Operative vaginal delivery 602, 618, 705
Opioid 282, 622
diagnostic of 444
poisoning, chronic 448
Opium poisoning 448
Oral anticoagulant 250
Oral cavity 91
Oral contraceptive pills, use of 460
Oral glucose challenge test 105, 230, 263, 545
Oral heart failure therapy 253
Oral hygiene 102, 760
Oral hypoglycemic agents 158, 261, 262, 262t
Oral iron 276
Oral steroids, indications of 394
Organ function assessment
quick sepsis-related 752t
sepsis-related 749
Organ systems, range of 405
Organogenesis 73
Orofacial clefts 329
Oseltamivir 323
Osmotic fragility 282, 286
Osmotic laxatives 305
Osteomyelitis 281
Osteonecrosis 281
Osteoporosis 306
Outflow tracts 142f
Ovarian artery ligation 647, 648f
Ovarian cancer 363
clinical presentation 363
management 364
Ovarian cystectomy 364
Ovarian follicle grows 53
Ovarian function 315
Ovarian germ cell tumors 364
Ovarian hyperstimulation syndrome 256
Ovarian ligament 657f
Ovarian torsion 198
Ovarian tumors, malignant 364
Ovary corpus luteum 85
Overwhelming post splenectomy infection 281
Ovular phase 65, 69
Ovulation 629
plasma membrane of 53
transport 54
administration 778
affinity, altered 279
consumption 84
delivery 762
concept of 762
saturation 752, 762
toxicity 717
Oxytocic drugs 730
use of 615
Oxytocin 247, 581, 588, 615, 645
contraindications for 644
drip 579
infusion 602
nasal spray 677
P-450 enzyme 321
Packed cell volume 767
Packed red blood cell concentrates 767
Pain 101
changes, location of 306
etiology 101
medication 282
relief 569
score 759f
treatment 101
types 101
Palatal anomalies 671
Pallor 91
severe degree of 430
Palmar edema 102
Palmar erythema 335
Palpable tender liver 325
Pancreatitis, acute 411, 430
Panel tests 190
Papillary necrosis, acute 281
Paracentesis, abdominal 432
Paracentric inversion 114, 115f
Paracetamol 622
Paralysis 316
Parasites 380, 451
Parasitic twin, external 464
Parathyroid glands 85
Paraxial mesoderm 76
Parenteral antiemetic therapy 304
Parenteral steroids, indications of 394
Parietal fascia 42
Paroxysmal disorder 327
Partogram 569
components of 572
Parvovirus B19 123, 381, 542
infection 123
Passive leg raise maneuver 762
Patau syndrome 67, 116, 129, 150, 186
Patent ductus arteriosus 247, 248, 254, 507, 683
Patwardhan's maneuver 589f, 614
Peak systolic velocity 169f
Pedal edema 102, 102f, 461
Pedicles 655
ligation of 658
anatomy 37, 604
architecture, influence of 553
assessment 230
brim 572
collections 667
diaphragm 41
fascia 42
floor muscle 39f
rehabilitation 639
grip 562
hematoma 38
infection, acute 428
inlet 44
kidneys 170f
musculature 630
organs 629
outlet 45
region, muscles of 41
shape 555
ureters 43
Pelvis, abnormal 588
Pemphigoid gestationis 337
Pena-Shokeir syndromes 496
Penicillin 323
G benzathine 374
Peptic ulcer
disease 305
perforation of 430
Per vaginal examination, procedure of 568b
Perfusion 702
Pericardial effusions 496
Pericarditis 294
Pericentric inversion 114, 115f
Periconceptional folic acid supplementation 74
Perimortem cesarean
delivery 776
section 247, 438
Perinatal asphyxia 684, 696698, 698fc, 699
causes of 696, 697t
neonatal signs of 698t
postpartum screening for 699
risk of 699
developing 683
screening tests for 699
Perinatal death 284, 720, 721
causes of 721b
classification of 721, 721b
majority of 720
notification of 724
surveillance 721, 722
Perinatal infection 73t
Perinatal management 701
Perinatal mortality
rate 720
risk increases 544
Perinatal transmission
estimated risk of 367
rate of 367
with intervention, risk of 367t
without intervention, risk of 367t
Perineal muscles 639
Perineal skin 639
Perineal tears 638
classification 638
management 639
risk factors 638
Perineal trauma 635
reduced 737
Periodic fevers 664
Peripartum cardiomyopathy 252, 325
Peripheral fat 348
Peripheral nerve injury 708
Peripheral nervous system 74
Peripheral neuropathy 327
Peripheral smear 275f, 286, 411
Peripheral vascular resistance 85, 233
Peripheral vasodilators 238
Peristaltic sounds 431
Peritoneal closure 614
Peritoneum 40, 630
reflections of 39f
Peritonitis, complications of 430
Pethidine 622
Pfannenstiel incision 612
Phenothiazines 304
Phenotype 114
Phenytoin 329
Pheochromocytoma 235
Phosphoenolpyruvate carboxykinase, activation of 683
Phosphorylated insulin 504
Phrenic nerve injury 709
Physiological adaptation 80, 85t, 266, 762
Pinard's maneuver 562f
Piper's forceps 560
Piperacillin 323
Pituitary gland 74, 84
Placenta 63, 69, 143f, 144, 227, 410, 478, 483t
abnormality 475, 478, 542
accrete spectrum, incidence of 169
delivery of 643
development of 58, 59f
diffusa 480
gross examination of 480f
increta 520, 532f
lacks 167
low lying 519
manual removal of 779
normal 478
percreta 520, 530f
posterior 152f
processing of 484b
removal of 730
shape, abnormalities of 478
single 459
size, abnormalities of 480
triangular projection of 459f
Placenta accreta 520, 530f
spectrum disorders 528, 529t
diagnosis 530
epidemiology 529
management 530, 534fc
Placenta previa 227, 502, 519, 520, 577, 653, 653f
accreta 529
diagnosis of 519f
incidence of 519
lateral 519
marginal 519
partial 519
previous 519
total 519
woman with 522
Placental abruption 283, 439
chance of 438
classification 524
clinical picture 523
complications 524
incidence 522
management 524
pathophysiology 522
previous 523
risk factors 523
Placental adherent syndrome 653
Placental block 546
Placental chorioangioma 496
Placental circulation 60f
Placental development 53, 59
Placental evaluation 483
Placental examination 229
Placental gene expression changes 405
Placental growth 58
hormone 98
Placental insufficiency 472, 541, 543, 715
Placental location 401
Placental morphology 401
Placental site trophoblastic tumor 211, 216, 223
Placental transfusion 715
Placental tropism 388
Placental tumors 480
Plaques 338, 338f
reduced blood 767
volume 104
Plasma protein
A, pregnancy-associated 134, 170
changes 106t
levels of pregnancy-associated 186
Plasmodium falciparum 388
Plate mesoderm, lateral 76
Platelet-rich plasma 767
Pleonasm 610
Pleural effusion 321, 401, 496
Pleuritic pain 310
Plotting partogram 572
Plugged ducts, management 672
Pneumococcal vaccine 95
Pneumocystis jirovecii 321
Pneumonia 282, 322, 380, 388, 430, 668, 710
bacteriology of 322
causative organisms for 323t
severity of 323t
Pneumothorax 710
Poikilocytes 286
quality improvement methodology 723
test 374
Poison 442, 443, 448
diagnosis of 443
effects of 443
fetal effects of 445
high risk factors for 443t
management of 444
medicolegal aspects of 444, 444b
Polar bodies, abnormal 68
Policeman tip appearance 708
Polyangiitis 315
microscopic 315
Polyarteritis nodosa 295, 315
Polycystic kidney 295
disease 472
Polycystic ovary syndrome 348, 420, 677
Polycythemia 684, 715
Polydipsia 304
Polygenic cardiac disease 244
Polygenic disorders 117
Polyhydramnios 158, 174, 474, 475, 475f, 496, 523
causes of 475
development of acute 462
etiology 474
fetal causes 474
incidence 474
mild 476
pathogenesis of 474
relief of 476
severe 476
Polymastia 631
Polymerase chain reaction 284, 384, 386, 387, 389
Polymicrobial infections 380
Polymorphic eruption 337, 338, 338f
Polypeptide chains 286
Polyploidy 114
Polythelia 631
Polyuria 304
Ponderal index 486
Portal vein thrombosis 418
Positive antinuclear antibody 309
Postabortion care 727
Postarrest prognostic factors 780
Post-cesarean analgesia 625
Postdural puncture headache, management of 746
Postmolar gestational trophoblastic neoplasia, diagnosis of 220t
Postpartum complication 463, 522
Postpartum convulsions 400
Postpartum hemorrhage, risk factors for 643t
Postpartum management 330, 353
Postpartum periods, management of 418
Postpartum pyrexia 663
clinical monitoring 666
complications 668
etiopathogenesis 664
history 664
investigations 665
management 667
physical examination 665
prevention 668
prognosis 668
risk factors 664
Postpartum surveillance 270
Postprocedural fetal loss rates 151, 154
Postresuscitation care 693
Post-term pregnancy 158, 473, 535
etiology 536
incidence 535
management 536
pathogenesis 536
prevention 537
Post-traumatic stress disorder 230, 340
Potassium chloride 206
Prader-Willi syndrome 68, 117
Pradhan Mantri Surakshit Matritva Abhiyan 730
Prazosin 237
Precipitate labor 573
Pre-conception and Pre-natal Diagnostic Techniques Act 320
Preconception care 88, 97
Preconception clinic 124
Preconception screening 124
Preconceptional counseling 88, 123, 245, 260, 269, 329
Predelivery, risk factors in 664t
Prednisolone 303, 315, 357
Prednisone 296, 332
Predominant bacterial organism 665t
Preeclampsia 109, 117, 119, 255, 267, 283, 293, 304, 310, 319, 324, 398, 399f, 406, 411, 412b, 541, 543, 758
anticonvulsants for 730
early-onset 399, 400
epidemiology of 398
etiopathology of 399
late-onset 399, 400
management of 403fc, 746
mild 403, 404
pathogenesis of 241
prevention of 296, 403
screening for 241
severe 239t, 292, 399, 404, 404t, 746
sign of 406
superimposed 239, 398
Pre-existing morbidities, pregnancy with 233
abnormal 301
autoimmune disorders of 308
causes of 293t
complications 283, 461
continuation of 362
dating of 536
dermatoses of 337
effects of 243, 295, 310, 312, 336
failure 127t
first half of 428
high-risk 737
intrahepatic cholestasis of 118, 409
management 350
morbidity 311
normal 53, 106
obesity 352t
progression, abnormal 174
research 33
second half of 428
stage of 539
treatment of 267, 294, 360
underlying risk of 256
vomiting of 412b
Pregnancy after previous fetal loss 227
etiology 227
evaluation of fetal death 228
management strategies 229
maternal evaluation 228
postnatal follow-up 229
risk assessment 228
Pregnancy loss 227, 312, 348
recurrent 67, 118, 199f, 348
second-trimester 199
Pregnant women, resuscitation of 744
Preimplantation genetic
screening 282
testing 298
Preinvasive disease 362
Premarital screening 124
Premature labor 324
Prenatal genetic screening test, timing of 135
Prenatal screening 330
Prenatal testing 190
Prepartum management 426
care 350
counseling 305
immunization 89
Preterm baby 713
Preterm birth 462
prediction of 508
Preterm delivery 294
Preterm infant 683
Preterm labor 154, 440, 503, 522
complications 507
diagnosis of 504
incidence of 350
management of 505, 506t, 507
predictors 504
prevention of 505
risk factors 503
treatment of 462
Preterm premature rupture of membranes 158, 389, 512, 516
complications 513
diagnosing 513
etiology 512
infections 512
management of 513
prediction of 513
Prevent circulatory collapse 437
Previous cesarean
delivery 582
section 519, 617, 617f
Primary health centers 729
Primary lactation failure 675
Primary milk insufficiency syndrome 675
Primi paternity, concept of 399
Primidone 329
Primitive chorionic villi 62
Proctosigmoidoscopy 432
Progesterone 98, 110, 258, 259, 291, 335, 505
only pills 240
Progressive familial intrahepatic cholestasis 409
Proinflammatory cytokines 504
Prolactin 98, 259
levels 298
Prolapse piles leads 306
Proliferated columnar endocervical glands, extension of 81f
Promethazine 304
Pronucleus, abnormal 68
Prophylactic forceps 599
concept of 599
Propranolol 237
Propylthiouracil 269, 270
Prostaglandin 206, 254, 547, 579, 643, 645
inhibitors 476, 506
Prosthetic heart valve 251, 252
binding 357
capacity 678
metabolism 82
synthesis 301
Proteinuria 109, 293, 401
hypertension without 643
management of 296
Proton pump inhibitor 305
Protozoal infections 380, 386t
Prune Belly syndrome 473
Pruritic folliculitis 337, 339
Pruritic uricarial pappules 338, 338f
Pruritus 102, 623
gravidarum 335
severe 335
Pseudomonas 380
Pseudoseizures 328
Psoriasis 316, 336, 671
Psychiatric medications 344
Psychogenic nonepileptic seizures 328
Psychological monitoring 760
Psychosis 341
Psychotherapeutic drugs 345t
Psychotropic drugs 345
Ptosis 344
Pubic symphysis 93f
Pubocervical ligaments 40
Pudendal block 624
Puerperal fever 663
Puerperal pyrexia 663
causes of 664, 664t, 666t
Puerperal sepsis 292, 663
delivery for 664t
labor for 664t
Pulmonary arterial hypertension 324
Pulmonary arterioles 688
Pulmonary artery 182f
bifurcation 182f
pressure 254
monitoring 758
right 182
Pulmonary edema 294, 324, 325
causes of 405
Pulmonary emboli, acute 255
Pulmonary embolism 282, 325
Pulmonary fluid secretion 472
Pulmonary function tests 318
Pulmonary hypertension 270, 281, 282, 324, 325, 507
consequences of 254
persistent 683, 684
primary 255
severe forms of 247
Pulmonary hypoplasia 465
Pulmonary infarction 282
Pulmonary stenosis 248, 251
etiology of 251
Pulmonary thromboembolic disease 254, 325
Pulmonary thromboembolism 771, 779
Pulmonary veins 179f
Pulsatility index 171f, 490
Pulse 628
oximetry 322, 756
reactivity score 758t
score 758
Purandare's system 646f
Pus, aspiration of 674
Push technique 588
Pustules 714, 714f
Pyelectasis 144
mild 146, 146f
Pyelonephritis 283
acute 430
Pyloric sphincter competence 305
Pyloric stenosis 475
Q fever 380
Quadruple test 134
Quantitative defect 279
Quantitative fluorescent polymerase chain reaction 120
Quiescent gestational trophoblastic disease 224
Quotidian 664
Radial aplasia 329
Radiation 6, 194
therapy 359, 361
Radical cesarean hysterectomy 363
Radical hysterectomy 363
Radical trachelectomy 363
Radiculopathy 624
Radiocolloid, dose of 356
Radionuclide scans 432
Ramipril 237
Range of movements 313
Rational emotive behavior therapy 344
Raynaud's phenomenon 671
Reactive nonstress test 159f, 160
Recombinant human erythropoietin 282
Rectal bleeding 430
Rectal examination 639
Rectovaginal fistula 638
Recurrent abortion 194, 198
causes 198
diagnosis 199
etiology 199
treatment 199
Recurrent pregnancy loss, causes of 200
Red blood cell 104
Red cell concentrate 767
Reflection and echoing 15
esophagitis 305
nephropathy 295
Refractory hypoxemia 254
Refractory neoplasia 222
Refuting misconception 676
Regional analgesia 623, 739
Regional anesthesia 353
Regress postpartum 336
Regular fetal antepartum testing 158
Regular perinatal death audits 723
Rehydration 304
Remdesivir 395
Remifentanil 622, 623
Renal agenesis 473f
Renal anomalies 68, 473
Renal causes, signs of 401
Renal disease 227, 291, 293, 295
chronic 194, 199
end-stage 295, 297, 764
pregnancy of 294
Renal evaluation 700
Renal failure 283
acute 98, 403, 747, 764, 768
anemia of 288
chronic 281
Renal function 155t
monitoring 759
parameters 108t
test 68, 107, 197, 218, 235, 403, 433, 443, 778
Renal impairment 304
Renal insufficiency 293
degree of 294
Renal parameters 665
Renal parenchyma 401
Renal pathology 235
Renal plasma flow 84
Renal system 84, 233
Renal transplantation, pregnancy after 298
Renal ultrasonography 68
Renal ultrasound 294
Replacement feeding 371
Reproductive autonomy 190
Reproductive capacity 298
Reproductive cloning 69
Reproductive health 729
Reproductive system 80
Reproductive tract, internal 39f
Rescue cerclage 200
Respectful maternity care 739
Respiratory arrest 304
Respiratory autogenic training 622
Respiratory changes 435
Respiratory depression 623
Respiratory disorders, management of 318
Respiratory distress 267, 476, 710
syndrome 683, 710
Respiratory function, monitoring 759
Respiratory physiology 318
Respiratory rate 430, 745, 754, 756
Respiratory signs 319
Respiratory symptoms 319
Respiratory system 92
Respiratory tract 84
Responsive feeding 632
Rest and exercise 632
Resuscitation 685, 688
Resuscitative cesarean section delivery 776
Resuscitative fluids, types of 764
Reticulocyte count 282
Retinal detachment 281
Retinal hemorrhage 707
Retinoids 335
Retinopathy of prematurity 683, 716, 717
examination for 716
Retinopathy, progressive 281
Retracted nipple 673f
Retroperitoneal adenopathy 321
Retroplacental bleeding 523
Retroplacental hematoma 524f
alloimmunization 150
immune globulin 149
incompatibility 518, 540
Rheumatoid arthritis 267, 308, 312
effects of 312
Rh-negative blood 694
Rhythm, assessment of 754
Ribonucleic acid 187f
Rickettsiae 380
Rifampicin 321, 371
Right umbilical vein, persistent 482
Right ventricular outflow tract 140, 175, 177, 180, 181
Ring chromosome 116
Ringer's lactate 304, 694, 764, 778
Ripening cervix, process of 579
Ritodrine 324, 507
Robertsonian translocation 115, 115f, 116
Robotic cerclage 201
Robotic surgery, form of 8
Root-cause analysis 722
Rosacral ligaments 40
Routine antenatal care 88
Rubella 94, 123, 194, 381, 451, 452, 542
Rubeola virus 384
Rubin's maneuver 606, 606f
Rupture uterus 616, 779
diagnosis 618
management 619
risk factors 617
Ruptured berry aneurysm 331
Ruptured ectopic pregnancy 207f
Rusty pipe syndrome 675
Sacral agenesis 72
Sacrococcygeal teratoma 72, 169, 496
Safe abortion services 729
Safe motherhood
initiative 725, 727
pillars of 727
Salicylate poisoning 445
Salivary estriol 504
surge, detection of 504
Salmonella 674
typhosa 451
Salpingectomy 207f
Salt restriction 237
Sampson's artery 657
branches of 654
Saphenous, varicosities of 336
Scalp electrode injuries 706
ectopic pregnancy 208f
endometriosis 638
integrity of 582
Schizophrenia 341, 343
Schlusskoagulum 71
Scleroderma 295, 313
Sclerosing cholangitis, primary 416
Seborrheic dermatitis 713
Sedation 150
Seizure 304, 344
absence of 327
activity 328
causes of 327
disorder 327, 328
persist 330
Selective estrogen receptor modulators 362
Selective serotonin reuptake inhibitors 72
Self-inflating bag 691
Sengstaken-Blakemore tube 646f
Sensory abnormalities 316
Sensory epithelium of ear 74
Sentinel node procedure 356
Sepsis 387, 743, 746, 766, 771
stage of severe 766
syndrome 283
Septate uterus 194
partial 199f
Septic abortion 194, 196, 196f, 201, 387, 743
management 197
pathology 196
surgery in 197
Septic shock 197, 768
Septicemia 194, 222, 430
Septostomy 461
Sequential organ failure assessment 388, 749, 752t
Serology 373
Sertoli cell function leading 348
alpha-fetoprotein, measurement of 134
beta-human chorionic gonadotropin measurement 204, 205
bilirubin 401, 714
complement levels 294
creatinine 294, 296
electrolytes 218, 443, 759
ferritin 274
human chorionic gonadotropin level 109t
lactate levels 107
tumor markers 364
Severe acute respiratory syndrome 455
conronavirus 383
Sex chromosome 68
anomalies 150
monosomy 133
Sex cord-stromal tumors 364
Sex hormone-binding globulin, levels of 348
Sexually transmitted disease 386, 727
Sexually transmitted infections 89, 367, 372
effects of 375t
Sheehan's syndrome 675
Shirodkar operation, modified 200
Shock 683, 762, 763t
classification of 763fc
maternal 440
moderate-to-severe 766
Shockable rhythms 775
Short obstetric forceps 596f
delivery of 553, 560
disimpaction, anterior 607
neglected 563, 563f
posterior 606f
Shoulder dystocia 604, 605, 605t, 608
complications 607
incidence 604
management 605
risk factors 604
right-to-left 254
vesicoamniotic 474
Sialidosis 496
Sickle cell
anemia 279, 280
C disease 280
crisis 255
D disease 280
disease 158, 279, 280, 283, 288
disorders 279
E disease 280
syndrome 282
thalassemia disease 280
trait 280, 284
Sickling process, stages in 280f
Sickling solubility test 282
Sickling test 282
Sideroblastic anemia 286, 288
Silastic vacuum cup 599f
Sildenafil citrate 474
Silent stroke 281
Simpson's long forceps 596
Single gene 116
defects 153
deletion 285
disease 124
disorders, diagnosis of 298
Singleton pregnancy 461, 463
Sinusitis 321
Sinusoidal pattern 591, 592f
Sirenomelia 72
Situs inversus 72, 176
Situs solitus 176
Skeletal defects 329
Skeletal system 107
Skilled birth attendant 728, 730
supervision of 728
Skilled manpower 28
Skin 81
changes 102
contact, direct 387
edema 496
incision 612
lesions 310
suturing 637
Skin-to-skin contact 686, 737
Skull 708
base 140
bones, overlapping of 540f
Sleep 632
pattern, abnormal 344
wake cycles 701
Sloping pelvic floor 552
Small cortical cysts 473
Smith-Lemli-Opitz syndrome 473
Sneezing 344
bicarbonate 305, 779
deficiency 715
dithionite, solution-like 282
nitroprusside 238
Soft markers, absence of 146
Soft tissues
injury 705
swelling of 705
Somite differentiation 76
Sonoembryology 126
Spalding sign 540f
Special poisoning syndromes 444
acrosome reaction 55f
oocyte binding 55
plasma membrane of 53
transport 54
Sphingomyelin 150
Spider nevi 335
Spina bifida 75, 147, 147f
Spinal anesthesia 611
high 779
Spinal cord
disorders 327
injuries 704, 709
Spinal epidural hematoma 624
Splanchnopleuric mesoderms 77
Splenectomy 288
Splenic sequestration crisis 281
Spontaneous labor, risk of rupture in 618
Spot urine protein 401
Squamous cell carcinoma 363f
Staphylococcus aureus 671
Static intensity 319
Static pulmonary function tests 318, 318t
Statins 244
Status epilepticus 330
Steal phenomenon 701
Stem cell transplant 287
Stenotic lesion 248
Sterile water injections 622
Sternal defects 78
Sternocleidomastoid muscle, spasm of 564
Steroid 394, 776
and immunosuppressive therapy 294
hormone 291
production 110
therapy 304
treatment 335
Stillbirth 319, 463
recommendation 548b
reduced 737
trends of 539
Stomach 142f
Stool culture 305
Streptococcus pneumonia 281, 323, 380
Streptomycin 321
Striae gravidarum 102f, 335
Striking basophilic stippling 286
Stroke 281
Strongyloides stercoralis 380
Structural chromosomal abnormalities 120, 298
Structural valve deterioration 251
Strychnine 444
Subcapsular hematoma 401
Subcutaneous fat necrosis 705
Subdural hematoma 707f
Subdural hemorrhage 706
Subfertility 348, 417
Subsequent pregnancy, management of 230, 639
Substance abuse 447, 543, 678
assessment 89
Substance use, management strategies for 344
Substantial blood loss 362
Subtotal obstetric hysterectomy 659f
Suburethral nodule 216f
Succenturiate placenta 479f
Suckling promotes 631
Sucralfate 305
Sudden collapse 778
Sudden obstetric collapse 770
clinical causes 770
supportive management 776
Sudden tumor collapse 220
Suicide 343
Sulfasalazine 313, 315, 317
Sulfonamides 390
Sulpiride 676
Supplementary therapy, role of 241
Supralevator hematoma 38
Suprapubic pressure 606, 606f, 607
Supraventricular tachyarrhythmia 253
Surgical scar, direct 529
Suturing muscles 637
Swansea criteria 304
Swansea diagnostic criteria 411b
Sweating 344
Symphysiotomy 607
Symphysis-fundal height, measurement of 93f
Symptomatic systemic
bacterial infection 703
congenital viral infection 703
Syndrome of inappropriate antidiuretic hormone 702
Syphilis 89, 94, 124, 373, 375, 374t, 376t, 384, 388, 451, 542
congenital 375, 376b, 453
pappules 374f
navirapine, dose of 370
zidovudine 370
Systematic analysis 178
Systemic absorption 323
Systemic diseases 194
Systemic lupus erythematosus 71, 124, 158, 199, 227, 235, 267, 308310, 337, 541, 544
effects of 310
management of 310
Systemic vascular resistance 85, 762
T sign 460f
Tachycardia 320, 387, 590, 718, 768
Tachypnea, transient 683
Tachysystole 581
Tacrolimus 303, 317, 418
Tactile stimulation 689
Takayasu arteritis 314
Talipes equinovarus, congenital 716f
Tazobactam 323
Tear drop cells 286
Teeth, enamel of 74
Telangiectasia 335
Telemedicine 28
practice guidelines 28
Tenderness, site of 431t
Tennessee classification 413
Tenofovir 368, 369
regimen of 369
Teratogen exposure, effects of 65f
Teratogenesis 71
Teratogenic drug 297
defects 73t
Teratomas, immature 364
Teratospermia 68
Terbutaline 324
Term breech trial 35
Terminal ileum 305
Termination of pregnancy 198, 201, 362
Tetanus toxoid 95
injection 197
Tetracyclines 320, 323, 390
Tetralogy of Fallot 254
Thalassemia 284, 287, 288
major 286f, 288f
mild 287
minor 284, 286
severe forms of 284
types of 284
Theca lutein cysts 218f
Therapeutic hypothermia 702
Thermal adaptation 682
Thermal injury 440
Thermoneutral environment 684, 685f
Thermoregulatory imbalance 345
Thiamine deficiency 99
Thiazides 237, 238
Thionamides 269
Third stage bleeding 247
Third-trimester 260, 460
Thoracic abnormalities 496
Thoracic cavity 78
Thoracoscopy 320
Thoracotomy tube 437
Thrombocytopenia 153, 309
Thromboembolism 252, 283, 328, 405
side effect of 767
Thrombophilia 523, 544
inherited 198
Thromboplastin 523
Thromboprophylaxis 282, 296
Thrombotic microangiopathy 293, 294
Thrombotic thrombocytopenic purpura, clinical syndromes of 293
Thumb technique 691
Thyroglobulin, proteolytic destruction of 270
antibodies 267
autoimmune disorders of 313
binding globulin 85f
production of 266
cancer 365
disease, screening for 266
disorder 201, 266, 271
treatment of 269, 269fc
dysfunction 198
function test 218, 751
levels of 107t
gland 84
functioning 266
hormone 267
physiology 266, 266t
peroxidase antibodies 270
physiology 106, 107t
stimulating hormone 68, 266, 268fc, 268t
storm 269, 270
treatment of 270, 270fc
Thyroiditis 270
postpartum 270, 314
Thyroid-stimulating antibody, formation of 268
Thyrotoxicosis 269
destruction-induced 270
Thyrotropin, inhibition of 266
Thyroxine 266
myocardial effects of 270
oxygenation 762
thromboplastin 523
Tocilizumab 395
Tocolysis 150, 297, 501, 506, 593
short-term 515, 463
Tocolytic agents 246t, 324
Tocolytic pulmonary edema 324
Tocolytic therapy 515
Tolbutamide 426
Tongue tie 671, 718
Topical bleaching creams 335
TORCH infections 59, 452
Total breech extraction 559
Total obstetric hysterectomy 654f, 660f
Touch technology 47
Toxic compounds
formation of 445f
pathophysiology of 445f
Toxic doses, radiation in 194
Toxic effects 303
Toxicologic analysis 443
Toxins, environmental 194
Toxoplasma gondii 451
Toxoplasmosis 123, 386, 452
T-piece resuscitator 691
Tracheal occlusion 78
Tranexamic acid 531
Tranquilizer poisoning 446
Transabdominal technique 151
Transcerebellar diameter 141f
Transcervical technique 151
Transcutaneous electrical nerve stimulation 622
Transfusion reactions 768
life-threatening 768
mild 768
moderately severe 768
Transient diabetes insipidus 411
Transplacental passage 453
Transplacental therapy, monitoring of 154
Transvaginal chorionic villus 151
Transvaginal scan 200, 204
Transvaginal sonography 519
Transvaginal ultrasonography 204
Transverse grooves 336
Transverse lie 502, 562, 563f, 577
Transverse section 143f
Trauma 434, 436, 439, 523
assessment of 436
causes of 436, 439
complications of 441
management of 436, 438
penetrating 440
signs of 438b
symptoms of 438b
types of 436
Trendelenburg position 685
Treponema 123, 373
infection 123
tests 374
Treponema pallidum 451, 453
hemagglutination 374
particle agglutination 374
Triaging policy 745
Trichomoniasis 336, 375, 386, 512
Trichuris trichiura 380
Tricuspid regurgitation 134, 251
Triglyceride 258
Triiodothyronine 266
Trimethadione 329
Trinucleotide repeats 120
Triple drug therapy 368
Triple X syndrome 186
Trisomy 67, 114, 129, 133, 135, 186, 189
screening for 230
sonological marker in 134t
Trophoblast 69, 213f
hyperplasia of 214f
normal 212
Trophoblastic disease 211
management of 222
Trophoblastic disorder 337
Trophoblastic invasion, second wave of 485
Trophoblastic lesions, pathology of 214
Trophoblastic tumor cells 217f
True knot 483
Trypanosoma cruzi 451
Tubal ectopic pregnancy, ruptured left 207f
Tuberculin skin test 320
Tuberculosis 124, 320, 321, 678
Tuberculous ulcer 430
Tubular necrosis, acute 292
Tumor 496
borderline 364
collapse 222
necrosis factor 512
Turner syndrome 68, 150, 186, 255, 256
phenotype features of 68f
Turtle sign 605, 605f
Twin anemia polycythemia
sequence 466, 496
syndrome 465
Twin fetuses, discordant growth of 466
Twin molar pregnancy 466
Twin pregnancy 158, 172t, 194, 224, 224f, 461
Twin delivery 462
Twin-to-twin transfusion syndrome 170, 463, 465, 465f, 476, 496
Typhoid 388
ulcer 430
Tyrosinase, upregulation of 335
Tyrosine kinase inhibitor 358
Ulcerative colitis 305
basic steps of 140f
biometry 95
Umbilical artery 162, 167, 482, 490
perivesical 170f
single 482
Umbilical artery Doppler
fallacy of 487
measurements, abnormal 689
serial worsening of 168f
velocimetry 592
waveforms 488f
Umbilical blood sampling, percutaneous 152
Umbilical cord 166f, 481
abnormalities of 481t
bleeding 154
clamping of 689
timing of 684
contents of 481
cyst 483
four vessel 482
normal 143f
segment 546
Umbilical granuloma 714, 715
Umbilical venous catheter 690
Undescended testis 715, 715f
Unicornuate uterus, inversion of 654f
Unilateral salpingo-oophorectomy 364
Uniovular twins 457
Uniparental disomy 116, 117
United Nations Children's Fund 670, 738
United Nations Population Fund 727
Universal vaccination 414
Unstable hemoglobin variants 279
Upper pedicles 658f
Upper respiratory tract infection 321
Ureaplasma urealyticum 504, 512
Uremic organ dysfunction 294
Ureter 43t, 235
Ureteric injury 662
Ureterovaginal fistula 652
Urethral obstruction 472
Urgent exploratory laparotomy 432
Uric acid 304
Urinalysis 197, 292, 293, 433
Urinary albumin 109
Urinary bladder 143f
Urinary casts 310
Urinary components 155t
Urinary dipstick method 401
Urinary infection 84
Urinary protein 108, 311, 401
Urinary sepsis, suspicion of 667
Urinary symptoms 99
Urinary tract 496, 628
infection 259, 380, 386, 389, 512, 652
obstruction, congenital 472
tumors of 295
Urine 628
albumin 401
analysis 107, 235, 282, 443
monitoring color of 759f
output 756
retention of 101
tests, rapid qualitative 443
Urine sample 109t
chemical examination of 109t
physical examination of 108t
types of 108t
Urogenital defects 329
Ursodeoxycholic acid 303, 410
Uterine activity 551, 554
classification of abnormal 554
Uterine anomalies 529
Uterine artery 164, 172f
blood flows, normal 172f
embolization 648, 649
retrograde 649f
ligation of 647, 648f
bilateral 647
Uterine atony 642
refractory 653
Uterine balloon tamponade 731, 732f
Uterine blood flow 85
Uterine closure 614
Uterine compression techniques 648
Uterine contractions 439
assessment of 438
Uterine dehiscence 617, 617f, 619fc
Uterine discharge 634
Uterine dysfunction 561
Uterine endometrium 53
Uterine evacuation 668
Uterine exteriorization 614
Uterine incisions 613
Uterine malformations, congenital 618
Uterine manipulation maneuvers 618
Uterine massage 643
Uterine pathology
primary 529t
secondary 529t
Uterine pedicles 659f
Uterine rupture 541, 583, 586f, 617f, 618, 619, 619fc
complete 617
effects of 620t
incomplete 617
previous 585
risk factors for 617t
risk of 617t
types of 617
Uterine scar
extension of 585
rupture, clinical features of 586
Uterine surgery 617
previous 585
Uterine vessels 658f
clamping of 662
Utero-ovarian ligament 531
Uteroplacental blood flow 81
Uteroplacental circulation, spasm of 543
Uteroplacental insufficiency 410, 440
Uterovesical interface evaluation 171f
Uterus 39, 80
appearance of 223f
brace suturing of 649f
dropsy of 211
enlarged 80f, 305
inversion of 779
involution of 629, 629f
layers of 40
ligaments of 40
lower segment of 39
myometrial wall of 647
parts of 39
relations of 40
round ligaments of 40
section of 223f
sub-involution of 633
Vacuum cup 600f
Vacuum extractor 599
complications 601
contraindications 600
over forceps, advantages of 601
principles of traction 600
steps of operation 600
Vagina 38
posteriorly 38
Vaginal birth 585
after cesarean
delivery 585
section 585, 618
spontaneous 739
Vaginal bleeding 216f, 439, 520, 523, 525, 712, 712f
Vaginal breech delivery, modes of 559
Vaginal candidiasis 101
etiology 101
incidence 101
treatment 101
Vaginal cerclage 200
Vaginal clindamycin 505
Vaginal delivery 247, 416, 578t
Vaginal discharge 712, 712f
Vaginal examination 92, 372, 438, 562, 581
Vaginal infection 505f
Vaginal insertion 462
Vaginal lacerations 607
Vaginal mucosa 639
suturing of 637
Vaginal swabbing 661
Vaginal vault 662f
Valproate 329
Vanillylmandelic acid 235
Varicella 123, 388, 542
zoster 382
virus 336
Varicose veins 102
etiology 102
treatment 102
Variola 194
Vasa previa 483, 526, 577
classification 526
clinical presentation 526
diagnosis 527
incidence 526
management 527
Vascular anastomosis 464
Vascular Ehlers-Danlos syndrome 256
Vascular endothelial damage 485
Vascular endothelium 349
Vascular thrombosis 311, 353
Vasculitis 314
Vasoconstriction secondary 400
Vaso-occlusive crises 281, 282
Vasopressin 779
Vasopressor support 324
Vasorelaxing agents 253
Velamentous cord insertion 482
Vena cava
compression of inferior 357
inferior 301, 320, 776
occlusion 771
superior 182f
Venous stasis 306
Venous system 163
Venous thromboembolism 283, 395, 522, 763
Ventilation 701
breaths 774
lack of 693
positive-pressure 690, 692
Ventral body wall defects 78
Ventricles 175
Ventricular fibrillation 775
Ventricular septal defect 77, 247, 248, 254
Verbal communication 12, 12t
Vermian agenesis 75
Vertical skin incision 532f
Vertical transmission, risk of 408
Vesicovaginal fistula 652
Vesiculobullous lesions 338
Vessel number 482
Vestibule 37
bulbs of 38
Vibroacoustic stimulation test 591
Vice versa 235
Vicious circle 523
Vigilant fetal monitoring 230
Vigorous suctioning 689
Villous dysmaturity 484
Villous invasion, depth of 529
effects of 48
incidents of 48
types of 47, 47f
Viral hepatitis 302t, 418
acute 414
Viral infections 194, 379, 381t, 451
Viral load test 369
Virus 451
Viscera herniate, abdominal 78
Visceral fascia 42
Visceral injuries 709
Visceral layer 76
Visceral situs 177
Visual aids 14
Visual disturbances 304
Vital signs 751
abnormal 754
physiological 759
unstable 430
Vitamin 633
A supplements 94
B12 99
B6 99
C 288
D3 296
K 330
deficiency 99
supplementation 304
Vitreous hemorrhages 281
Voluntary muscles, movement of 539
Vomiting 98, 99, 304, 430, 717
complication 98
examination 99
excessive 461
investigations 99
treatment 99
Vulval hematoma 38, 637
Vulval lacerations 607
Waiter's tip deformity 713
Wandering method 599
Warfarin 244, 252
overdose 767
Warm stool smears 433
Warm water immersion 622
Water intoxication, risk of 645
Water metabolism 82
Waterborne transmission 387
Weak cry 688
Wegener granulomatosis 315
Weight gain 82
range of 92t
Weight loss 237
Weight management 237
Wernicke's encephalopathy 99
Wheezing 283
White blood cell count 431
White coat hypertension 234
Whole blood 766
finger prick test 371
Whole exome sequencing 120
Whole genome sequencing 120
Widal test 666
Wilson's disease 416
Witch's milk 711
Woman's dating ultrasound scan 190
Woman's death 5
Wood's screw maneuver 606, 606f
Wound dehiscence, incidence of 638
Wound infection 387
Wurm's stitch 201
X chromosome 67, 114
X-linked dominant disorders 117b
X-linked recessive disorders 117b
Y chromosomal microdeletion 68
Yellow atrophy, acute 304, 410
Yolk sac, secondary 70
Zanamivir 323
Zarate 262
Zavanelli maneuver 607, 608f
Zidovudine therapy 454
Zika 123
virus 383, 542
Zinc 282
Zona pellucida 57
glycoprotein of 53
penetration of 55, 56f
Zona reaction 54, 56
Zona thinning 70
Zoonotic disease 380
Zoonotic transmission 387
ZPP test 287
Zygosity 458, 458t
Zygote 53
division of 69, 458, 458t
Chapter Notes

Save Clear

1Obstetrics and Perinatology
  • Introduction to Obstetrics
  • Normal Pregnancy
  • Fetal Evaluation
  • Early Pregnancy Complications
  • Pregnancy with Pre-existing Morbidities
  • Maternal Complications Arising in Pregnancy
  • Fetal Complications
  • Late Pregnancy Complications
  • Labor
  • Postpartum Issues: Maternal and Neonatal
  • Social Obstetrics
  • Critical Care in Obstetrics2

Introduction to ObstetricsSECTION 1

Parikshit Tank
The study of history is a window into the minds of the thinkers and influences that have brought science to the current state. It is not merely a collection of facts or a source of trivia, but an evolution of thought and attitude that determines history in any field. History is the witness that testifies to the passing of time; it illuminates reality, vitalizes memory, provides guidance in daily life and brings us tidings of antiquity.1 The history of women's health is very broad. There are fragments of the history of evolution, humanity, medicine, and specific techniques. But it is also a history of the place of women, their achievements and the attitudes toward them with the passage of time.
To set the context in terms of evolutionary history, Figure 1 is a broad timeline of the universe, which is believed to be 14 billion years old. Homo sapiens or modern man has existed for about 200,000 years which is a tiny fraction of the age of the universe. Modern history is then, just a blink of an eye in such a large timeframe. Table 1 indicates the division of the more recent timeline into historical ages. Though this construct is simplistic, it helps to describe and structure the discussion on historical evolution.
zoom view
Fig. 1: Broad timelines of the universe.
The earliest representations of the female form date back to about 20,000 years bce. This was in the form of cave drawings and stone figures. One of the oldest preserved statuettes is the Venus of Willendorf from the Middle Aurignacian period somewhere in Western Europe. The statuette probably represents a fertility goddess.2
There are scattered instances of cave drawings, figurines, statuettes and representations of the female form till about 2,000 bce when the Indus valley came into existence. As we explore the origins of recorded and credible medical history and science, a central theme which emerges is that much of medicine seems to have evolved in the Indus valley. There are some records that the uterus was identified as a separate 4organ with a study of its function as early as 900 years bce.
TABLE 1   Historical ages and women's health.
Important events related to women's health
200,000 years ago till Before Christ Era (bce)
  • Earliest references to women's bodies, their anatomy in recorded history
  • Indus valley civilization, Upanishads (Garbha Upanishad) and Ayurveda addresses women's health and science
After Christ Era to 5th century Anno Domini (ad)
Ancient history
Greek, Egyptian and Middle Eastern science predominate the world
5th–15th century ad
Dark ages
Older Roman and European literature on women's health and the misconceptions
Initiation of scientific study of human anatomy and health in Europe
Early modern history
Rudimentary surgery and medicinal cures
1850s onward
Late modern history
Rapid revolutionary strides in all aspects of health and those pertaining to women's health
Current times
Contemporary history
Subspecialization and evolution of molecular technology
The Hindus (in this context, it means people of the Indus valley) recorded this in the Rigveda. The Garbha Upanishad describes the formation of the embryo, its growth in the uterus, the time of pregnancy at which it can be deemed viable and the process of labor. These observations are in line with the knowledge we have today. It also contains spiritual and philosophical discussions which are not possible to substantiate even with the current state of knowledge as these deal with fundamental questions such as the origins of life and the place of self in the cosmos.3 Much of this knowledge remained mysterious and inaccessible to the rest of the world for centuries to follow.
In this period, the study of human beings, medicine, and philosophy was largely in the Greek, Roman, and Middle Eastern empires. Hippocrates, Heraclides and a number of Greek and Roman physicians wrote about birth and diseases of women in general. However, the authoritative treatise on the subject of women's disease in those times came from Soranus. He was a Greek scholar born in the city of Ephesus. The city was a seat of learning and housed the great library of Celsus. In the first century ad, Soranus published on the diseases in women: De Morbis Mulierum. He gave an accurate description of the human uterus, correctly describing the size, position, layers, and internal structure. It was clear from his descriptions that he had access to studying human cadavers. Soranus is also credited with performing the first recorded hysterectomy for prolapse, which was more of an amputation than a surgery.4 Another figure of note is Agnocide. There is debate about the veracity of her story and her origins. She was an exception to the gender rule and is perhaps the first woman midwife of record. She had to dress herself up as a man to render her services and was so popular among women that she was accused of seducing them. In court, she was exonerated when she revealed her gender.5 A better documented history belongs to the Roman midwife Scribonia Attica whose tomb in Ostia, near Rome is maintained even today. It has bas-relief of her at work in a special birthing chair. Incidentally, she married an equally illustrious surgeon of the times, Marcus Ulpius.6
For religious and political reasons, cadaver study was banned in much of the Western world after the second century. Cadavers were difficult to obtain, their study was strictly regulated and performing dissection was punishable by law. Autopsies were meant only for the clergy and royalty. This inhibition of exploration and knowledge led to the Dark Ages. Myths abounded. One of the enduring myths which originated at this time was that the uterus was responsible for hysteria. The uterus was depicted as a separate animal, a parasite in the woman's body. The anatomy of the female body was represented wrongly with many descriptions being far removed from reality in Arabic, European, and Persian texts. Anatomical descriptions ranged from the simplistic to the ridiculous. One of the most popular ones was that the uterus was made up of two compartments, separate for male and female fetuses. A seven compartment model was also proposed. The fetus would occupy a different compartment based on the day of the week it was conceived. Science stagnated and knowledge from the ages before was drowned in a pool of ignorance and myth.7
In the West, in the 1600s, the change in the political climate saw a change in the mindset of the leading thinkers—scientists, artists, and scholars. Anatomical dissection and study of the 5human body resumed in the 16th century. A notable figure in this context is Andreas Vesalius from Belgium. Much of the knowledge and detailed description from this time comes from his treatise, De Humani Corporis Fabrica. It had the first good illustrations and descriptions of the uterus in modern times.8
In women's health, perhaps the most significant change was the scientific understanding of the process of vaginal delivery. The accurate description of the cardinal movements of the fetal head through the maternal pelvis was given by a Scottish obstetrician, William Smellie. But even more significant was the discovery of the obstetric forceps. Before the obstetric forceps came into being, obstructed labor was dealt with by destructive operations. The history of this instrument is one filled with myth and wonder. The Chamberlen family of French Huguenots from Normandy is credited with this invention in the 1570s, more specifically, Peter (the Elder) Chamberlen. He was appointed as the royal obstetrician to the English and French courts. The forceps was a secret instrument which only the members of the Chamberlen family used. It remained hidden for about 150 years after its invention. Much later, in 1813, Peter Chamberlen's tools were discovered in an attic of a house in Mortimer Hall in Oxford, United Kingdom. The forceps is an instrument that has undergone innumerable iterations and will forever be in a state of evolution. Notable Indian contributions to the field were from Sir Kedarnath Das (modification of the Simpson's forceps making it lighter and more friendly to the maternal pelvis) and Dr Aroo Mulgaonkar (modification of the Kielland's forceps). James Young Simpson made a significant contribution to the advancement of the forceps and also described the use of the first vacuum device—the suction tractor—to facilitate delivery.9
An important event in women's health in this period was the first recorded intentional cesarean birth where the mother and the child survived. There are anecdotal reports dated before this where babies have been delivered by cesarean performed by mothers themselves or accidentally by injuries from horns of livestock. But these are to be considered with due skepticism. In 1500, Jacob Nufer, a gelder in Switzerland recorded this event. His wife was in labor for days and despite help from a number of midwives, could not be delivered. He sought permission from the authorities and with his rudimentary knowledge of animal husbandry, performed a cesarean birth for his wife. The mother and child survived. The couple had five more children.10
The early modern history of women's health is marked by a number of innovations from “medicine men”. These were times of great advancements in chemistry and experimentations with newly discovered elements and compounds on the human body. There were also some attempts at characterization of herbal and vegetable products by their chemical composition.
In women's health, surgery made some progress. Before the 19th century, vaginal hysterectomies were largely palliative procedures for cervical cancer. The first planned, successful vaginal hysterectomy is credited to JCM (Conrad) Langenbeck in 1813. Around the same time, other surgeons such as Osiander, Dupuytren and Hatin had also performed vaginal hysterectomies but these were either accidental or emergencies (for severe hemorrhage in cervical cancer or uterine inversion) or resulted in the woman's death. Langenbeck operated on a 50-year-old woman with cervical cancer. There was alarming hemorrhage toward the end of the surgery. Working without an assistant, anesthesia, or a hemostatic forceps, Langenbeck heroically compressed the bleeding part with his left hand and managed to throw the last hemostatic suture with his right hand, holding the other end between his teeth. The woman survived—almost miraculously.11
Another advance in surgery on women was made in deliberately opening the abdomen to remove an ovarian cyst by Ephraim McDowell in Kentucky in 1809. The first abdominal hysterectomy was performed by Charles Clay in Manchester, England in 1843; unfortunately the diagnosis was wrong and the patient died in the immediate postoperative period. The following year, Charles Clay was almost the first to claim a surviving patient; however, she died postoperatively and it was not until 1853 that Ellis Burnham from Lowell, Massachusetts achieved the first successful abdominal hysterectomy although again the diagnosis was wrong. He was performing exploratory surgery for what he believed to be an enlarged ovarian tumor. During the procedure, the patient vomited, pushing an enlarged uterus through the abdominal incision. Burnham was unable to reduce it into the abdominal cavity, and had no alternative but to remove it. The woman survived the procedure.12
Medical science as we know it today had its Big Bang moment in the early 1900s. There were rapid strides in every field of science. The cross applications into medicine significantly improved safety and technique in medical practice and surgery. The most significant strides are outlined in Table 2. These are general advances but had an important role to play in women's health, just as for everyone else.6
This period of history saw some events in medical history specific to women which form the basis of care even in modern times. These advances and discoveries have shaped women's health in the most significant of ways. Some of these are highlighted here.
Childbirth fever was recognized as a ruthless killer since 3,000 years. Various myths surrounded its causation including remorse, possession by spirits, seduction, and fretting. The institutionalization of obstetrics in the 18th century brought a keen focus on the problem.6
TABLE 2   Significant strides in general medical practice in the 1800s onward.
Background and comments
Francis Bott (USA), Robert Liston (UK)
Started consistently using ether for anesthesia in surgery
James Young Simpson (UK)
Advocated the use of ether inhalation as an analgesic in labor
John Snow (UK)
Replaced ether with chloroform, which was safer. Administered analgesia to Queen Victoria during childbirth and gained royal backing and widespread approval for anesthesia by chloroform
Louis Pasteur (France)
Proposed the germ theory, mechanisms of infection and decay and possible methods to avoid the effects of microbes
Early 1900s
Joseph Lister (UK)
Applied the principles of germ theory to surgical practice and devised the antisepsis system which forms the basis of infection control till date
Blood transfusion
Karl Landsteiner (Austria)
Described the ABO system of blood groups and the technique of crossmatching, making transfusions compatible
Wilhelm Röntgen (The Netherlands)
Röntgen was studying the effect of passing electricity through a gas at very low pressures and noticed the effect on a plate. He took an impression of his wife's hand and this was the first Roentgenogram (X-ray)
Marie Curie, Pierre Curie, Henri Becquerel (France)
Jointly, these three scientists described the theory of radioactivity. Marie Curie further went on to discover two elements—radium and polonium. She also described isotopes which are important tools in the treatment of cancers
Frederick Banting and Charles Best (Canada)
Banting, an orthopedic surgeon and Best, a research assistant studied glucose metabolism in dogs who had been subjected to removal of the pancreas and developed diabetes. John Macleod was instrumental in purifying the extract called “isletin” for human use
Alexander Fleming (UK)
Serendipitous observation of elimination of bacterial growth due to the growth of a mold (fungus) identified as Penicillium
Various scientists working in the United Kingdom
Various scientists working in Oxford—Howard Florey (Australia), Ernst Chain (German), and Dorothy Hodgkin (UK)—worked out the chemical structure of penicillin and mass produced it for clinical use
Oliver Wendell Holmes, though not an obstetrician, was an astute clinician and hypothesized that childbirth fever was contagious and could possibly be prevented. It was Ignaz Philipp Semmelweis, a Hungarian physician working at the University of Pest who took a keen interest and studied this subject. He observed that units where care was provided by midwives had a tenfold lower rate of puerperal fever than where care was provided by medical students and doctors. This difference was that midwives did not conduct autopsies. He further studied the autopsy findings of women who died of puerperal fever and concluded that they arose due to “toxins”. To perform detoxification, he advocated washing hands, and later instruments and the entire ward with a chlorinated solution of lime. This nearly eliminated mortality from puerperal fever. However, his findings were treated with scorn and he was dismissed from his professional position. Ironically, he died of sepsis himself, in a mental asylum. It was only later that the value of his observations was realized and he was feted.13
Surgery became safer with the practice of anesthesia, antisepsis, blood transfusions, and antibiotics. Performing an operation was not looked upon as a death sentence anymore and it became a reasonable option for treating certain conditions. The rapid evolution of safe surgery had a major impact on the practice of cesarean birth. From the practice of leaving the uterine wound open, to exteriorizing or cauterizing it to finally, suturing it the cesarean operation was largely an upper segment procedure. It was the untiring advocacy and practice in the 1920s of John Munro Kerr in Britain and Joseph B DeLee in the United States that the operation became a lower segment procedure. Munro Kerr is said to have exclaimed “Hallelujah! The battle's o'er; the victory's won” when the Royal College accepted that the lower segment procedure was the superior one.14
Around the same time, Professor Henry Dale, a British pharmacologist described the uterotonic actions of oxytocin in 1906. Oxytocin was also the first ever polypeptide hormone to be sequenced and synthesized. This of course was much later in 1953 by the French chemist, Vincent du Vigneaud.15
A pioneer who was inspired by personal tragedy was Victor Bonney. His wife had large fibroids causing intractable symptoms which resulted in a hysterectomy. The couple was left childless. Working at the Chelsea Hospital for Women in London, Bonney refined the myomectomy and ovarian cystectomy in the 1920s. He is looked upon as a major influence in propagating the concept of organ preservation in gynecological surgery.16
As with conservative gynecological surgery, the hysterectomy operation was also progressing in technique. 7The mortality rates of the 1880s in the range of 75% were down to 2–3% by the 1920s. This was keeping in line with the general improvements in surgical outcomes. In the 1920s, two important advancements were the development of the total hysterectomy with the removal of the cervix by Richardson in United States of America and the use of the lower transverse abdominal incision by Johannes Pfannenstiel in Austria.17
The field of contraception saw some great improvements moving away from the myth-bound traditional techniques which were marred by risk and dubious efficacy. The intrauterine device is a classic example of a technique that has had a long evolution. From the legends of pebbles being inserted into the wombs of camels in the Middle East centuries ago, we know that the concept of a foreign body in the uterus providing contraception is not a new one. In modern history, the first intrauterine device that was published and invented in 1909 by Richard Richter in Germany. It was made of two strands of silkworm gut with a bronze filament thread to diagnose expulsion and retrieve it. Some early devices were the Grafenberg ring (Germany) and the Ota device (Japan). The devices evolved in term of design (rings, coils, loops, T-shaped frames) and content (nonmedicated, silver, copper and hormones) and have reached a point where low-dose hormones can be delivered directly into the uterine cavity.18
Perhaps the single most important change in women's health which empowered women to a greater extent than any other came with the evolution of hormones and the oral contraceptive pill. Oral contraception was practiced with herbs, roots, minerals, and oils. However, a reliable method did not exist. Edgar Allen and Edward Doisy published about the hormonal activity of the “ovarian hormone”; this was estrogen. Early work on the extraction of progesterone was being done in the 1930s by Russell Marker and Carl Djerassi which was important for the mass production of the hormone. It was the passion of Margaret Sanger, the capital of Katherine McCormick, the pharmacological genius of Gregory Pincus and the clinical responsibility of John Rock that saw the birth of the pill.19 It was introduced in the United States of America in 1955 under the guise of regularizing the menstrual period and ironically, to promote fertility. However, further trials in Latin America proved its efficacy as a contraceptive. The pill has undergone generations of changes and today, more than a 100 million women use it.
Women's health, just like all other medical fields, has diversified vastly in contemporary history. This has come about through an amalgamation of various medical and nonmedical specialties especially genetics, molecular biology, radiology, and engineering in various contexts (mechanical, electrical, and lenses). Over and above all these are the overarching influence of an exponential rise in the computing power that is available for research and day-to-day clinical practice. These have changed the way medicine in general and women's health in particular is practiced.
The treatment of cervical cancer had been proposed, studied, and practiced with varying degrees of success and safety. The early 1900s saw the emergence of the “radical hysterectomy” under the surgical expertise of surgeons such as John Clark in the United States of America and the Austrian teacher-pupil team of Friedrich Schauta and Ernst Wertheim. The technique was refined to a great degree in the 1940s by Joe Vincent Meigs in the United States of America.17 These techniques along with radiotherapy had reduced mortality from cervical cancer to some extent. However, in terms of public health, the big breakthrough in women's cancer care came from early detection by a cervicovaginal smear. Since the 1960s, this is arguably the most successful preventive health program in any form of medicine. The success stories have been resounding and repeated across geographies. The credit goes to a Greek military doctor, George Papanicolaou, who migrated to the United States of America. His wife, Andromache (Mary) Mavroyeni, whom he met on the ferry crossing, was an equal contributor to the research.20 In the 1940s, they teamed up with Herbert Taut, a gynecological pathologist at the Cornell University and published on the early detection of uterine cancer by vaginal smear.21 The practice was adopted gradually and is a routine test in modern times.
The Second World War brought great tragedy but also saw advancement in technology. One such instance was the use of SONAR (sound navigation and ranging) for submarines. Later, the same technology was extrapolated to medical imaging. Ian Donald was the epitome of a modern day renaissance man for obstetrics. He was born in Cornwall, United Kingdom and after spending his childhood in South Africa, returned to practice in the United Kingdom in the 1930s. After his wartime assignment as a Royal Air Force pilot, he specialized in obstetrics and published the treatise on Practical Obstetric Problems, which has undergone a number of editions and is still in circulation. But his most significant work came through his curiosity about imaging. He worked with Tom Brown, an engineer at the Babcock and Wilcox factory at Renfrew and devised the first contact scanner. They published their work and laid emphasis on the instant feedback that the technique provided.22 Ultrasound has become a specialty in its own right and has made it possible to treat the fetus as a patient in today's world.
Just as the imaging, the field of endoscopy has evolved from a similar curiosity to understand the internal structure and function of human beings. The revolution of endoscopy had begun in the early 1800s, with the work of Philipp Bozzini. In 1869, Pantaleoni from Ireland looking into the uterine cavity of a postmenopausal woman with a modified cystoscope and candlelight. This was the first hysteroscopy and he even went on to operate on the uterine polyps by cauterizing them with silver nitrate. It was only in the 1970s that hysteroscopy 8progressed from being a novelty to a reasonable treatment option. Neuwirth and Amin reported the first series of hysteroscopic submucous fibroids excision in 1976. In 1987, Alan DeCherney at the University of California, Los Angeles (UCLA) described the use of a urological resectoscope to treat intractable uterine bleeding.23 Similarly, by the 1900s, various surgeons had described laparoscopy but it was Harry Reich, who first published about laparoscopically assisted vaginal hysterectomy in 1989 and Kurt Semm described the classic intrafascial serrated edged macro-morcellator (SEMM) hysterectomy in the early 1990s. This has paved the way for innumerable innovations and changed the approach to surgery in the pelvis. Today, we are looking at the frontiers in the form of robotic surgery.17
In 1978, one of the most revolutionary events occurred with the birth of Louise Brown. Ordinarily, the birth of a girl in a remote English town would not have been newsworthy, but she was on the front page of every newspaper in the world, for she was conceived outside a human body. Apart from her parents and nature, she was as much a creation of Patrick Steptoe and Robert Edwards. Patrick Steptoe was a naval surgeon and after the war, his career interest was in laparoscopic surgery. He published on the detection of ovulation in women by laparoscopy. This caught the attention of Robert Edwards, who was studying oocytes maturation in mammals. His work was facilitated by Molly Rose, who provided him with ovarian tissue resected from women with Stein–Leventhal syndrome (modern day polycystic ovarian syndrome). The partnership between Edwards and Steptoe began with a phone call and flourished at the Oldham and District General Hospital. The first attempts were futile and in fact, the first in vitro fertilization pregnancy was an ectopic. Working against the odds and with courageous and persistent patients, the field of assisted reproduction was born with success in the form of Louise Brown's birth. Since then, various technological advances such as intracytoplasmic sperm injection, culture systems and robust equipment, and drug protocols have changed the face of human reproduction forever.
Human attitude and behavior is a product of the times and what is deemed to be acceptable in those times and circumstances. There could be a lot said and criticisms leveled about each and every advance of science in terms of the documentation, consent, and safety standards when compared to current ones. However, these criticisms could be dismissed as hindsight. But there are certain events in medical history which are unacceptable by any set of standard scientific or human behavior.
James Marion Sims is a classic example of such a revised view of historical events.24 He was arguably the greatest American gynecological surgeon and was regarded as the “Father of Gynaecology” in the United States of America. His fame grew from the surgical technique for the repair of vesicovaginal fistulae. Even though he eventually perfected the technique and the principles are in use even today, it is the way in which he conducted the surgical experiments that has changed modern views about him. The criticisms that have been leveled against him are that he experimented on African slaves without their consent. The surgeries were repeated over and over again on the same individual. Among the first women who had the surgeries were Anarcha, Betsy, and Lucy. It is estimated that there were forty surgeries conducted on them before a successful result was achieved. More disturbingly, Sims would not use anesthesia for these women, even though ether anesthesia was established practice. This was a racist attitude as he would perform the same procedures under anesthesia for white women. The changed views on Sims have led to a fall from grace as was witnessed by the removal of several of his statues in American cities.25
Scientific knowledge has advanced in subhuman conditions at times. War, genocide and unethical acts have been involved in the advancement of scientific knowledge and knowledge about women's health care. Some examples are the knowledge about the timing of Anti-D administration from the work of Nazi physicians in the Second World War, the use of cervical cancer cells from Henrietta Lacks without her consent or even acknowledgment and so many others. As history evolves, there is bound to be revisionism and changes in our view of events of the past.
Indian gynecologists have in the large part embraced modern practice and have contributed to scientific advances with some important works. One name that stands out is that of Professor VN Shirodkar. In the 1950s, second trimester abortions were a mysterious entity. He studied the cervix in the nonpregnant and pregnant states, understanding the changes in anatomy and physiology. He was particularly interested in the changing nature of the cervix in normal pregnancy from a fibrous one to a dynamic muscular organ. His answer to the problem of habitual second trimester abortion was a surgery which put India firmly on the map of operative obstetrics and gynaecology. In 1955, Shirodkar described the cervical cerclage operation. Over time, it has been modified by many surgeons, most notably by McDonald, but the original surgery is a masterpiece. Through his illustrious career, he developed various gynecological surgical techniques for tuboplasty, vaginoplasty, and sling surgery for conservative repair of prolapse.26
The problem—genital prolapse and its conservative repair—has been addressed by doyens of Indian gynaecology including VN Purandare, RP Soonawala, Brigadier SD Khanna, and Ajit Virkud. These surgeries have been innovative and scientific. They are being modified to suit the laparoscopic route.27
Professor VB Patwardhan is credited with describing formally, the technique of delivering the fetal head that is 9impacted into the pelvis in the second stage of labor.28 This technique is now accepted to be a better alternative to pushing the head up in terms of reducing maternal and fetal injury and morbidity.
One of the tragic events in Indian gynecological history is the life and death of Professor Subhas Mukhopadhyay. He created history in India working with Sunit Mukherji, a cryobiologist and gynecologist Dr Saroj Kanti Bhattacharya. This team was responsible for the birth of Durga (Kanupriya Agarwal) in October 1978, just a few months after Louise Brown. However, Mukhopadhyay faced criticism, ostracism and was driven to suicide by the hostility of the bureaucracy and the state government of the day. It was only later that his contributions were acknowledged and accepted.29
The history of medicine is impossible to encapsulate completely in a text of any length. This chapter is a bird's eye view of the important events and milestones that have shaped how we care for women in today's time. It is hoped that it serves as a stimulus for the interested reader to delve deeper into history and to reflect on the road ahead.
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  1. British Broadcasting Corporation (BBC). The Story of Medicine. London: Immediate Media Company;  2017.
  1. Green MH. The Trotula: An English Translation of the Medieval Compendium of Women's Medicine. Pennsylvania: University of Pennsylvania Press;  2010.
  1. Fulton JF. Logan Clendening Lectures on the History and Philosophy of Medicine. Vesalius Four Centuries Later. Lawrence, Kansas: University of Kansas Press;  1950. [online] Available from: [Last accessed September, 2021].
  1. Drife J. The start of life: a history of obstetrics. Postgrad Med J. 2002;78:311–5.
  1. US National Library of Medicine. (1993). Cesarean section - a brief history. [online] Available from: [Last accessed September, 2021].
  1. Senn N. The Early History of Vaginal Hysterectomy. Chicago: American Medical Association Press;  1895.
  1. Sutton C. Hysterectomy: a historical perspective. Baillieres Clin Obstet Gynaecol. 1997;1:1–22.
  1. Dastur AE, Tank PD. Milestones: Ignaz Philipp Semmelweis and puerperal fever. J Obstet Gynecol India. 2008;58:206–7.
  1. Baskett, T. On the Shoulders of Giants: Eponyms and Names in Obstetrics and Gynaecology, 2nd edition. London: Royal College of Obstetricians and Gynaecologists;  2010. p. 214.
  1. Magon N, Kalra S. The orgasmic history of oxytocin: love, lust, and labor. Indian J Endocrinol Metab. 2011;15:S156–61.
  1. Chamberlain G. Victor Bonney: The Gynaecological Surgeon of the Twentieth Century, 1st edition. London: CRC Press;  2000.
  1. Sparic R, Hudelist G, Berisava M, Gudović A, Buzadzić S. Hysterectomy throughout history. Acta Chir Iugosl. 2011;54:9–14.
  1. Thiery M. Pioneers of the intrauterine device. Eur J Contracept Reprod Health Care. 1997;2:15–23.
  1. Dastur AE, Tank PD. The oral contraceptive pill: the early days of a 50-year old legend. J Obstet Gynecol India. 2010;60:207–9.
  1. Dastur AE, Tank PD. George Papanicolaou and the cervicovaginal smear. J Obstet Gynecol India. 2009;59:299–300.
  1. Papanicolaou GN, Traut HF. The diagnostic value of vaginal smears in carcinoma of the uterus. Am J Obstet Gynecol. 1941;42:193–206.
  1. Donald I, MacVicar J, Brown TG. Investigation of abdominal masses by pulsed ultrasound. Lancet. 1958;1:1188–95.
  1. Tarneja P, Duggal BS. Hysteroscopy: past, present and future. Med J Armed Forces India. 2002;58:293–4.
  1. Wall LL. The medical ethics of Dr J Marion Sims: a fresh look at the historical record. J Med Ethics. 2006;32:346–50.
  1. BBC News. New York: James Marion Sims statue removed from Central Park. BBC Online. April 17, 2018.
  1. Shirodkar VN. Contributions to Obstetrics and Gynaecology. London: E and S Livingstone Ltd.;  1960.
  1. Virkud A. Conservative operations in genital prolapse. J Obstet Gynecol India. 2016;66:144–8.
  1. Patwardhan BD, Motashaw ND. Caesarean section. J Obstet Gynecol India. 1957;8:1–15.
  1. Mukherjee S, Mehta RH. Dr. Subhas Mukherjee: A Visionary and Pioneer of IVF. Mumbai: ICMR-National Institute for Research in Reproductive Health;  2020.
1. What are the important events in the 1800s that contributed to safety of surgery on women and in general?
2. Write an overview of the important contributions of Indian obstetrician and gynecologists in modern practice.
3. Write a critique the statement “James Marion Sims as the father of modern gynaecology”.
1. Write a short note on the history of the obstetric forceps.
2. Why was puerperal sepsis a deadly disease and how did Semmelweis deal with it?
3. Ian Donald is looked upon as the modern day legend in obstetrics. Mention his stellar contributions.
4. How has the history of assisted reproduction been rewritten in India in recent times?10
1. What is the estimated age of the universe?
  1. 34 billion years
  2. 14 billion years
  3. 4 billion years
  4. 1 billion years
2. From how long ago are the oldest representations of the female form and anatomy?
  1. 50,000 years bce
  2. 40,000 years bce
  3. 20,000 years bce
  4. 2,000 years bce
3. The following Indian text has the earliest scientific description about embryology:
  1. Govind Upanishad
  2. Yuga Upanishad
  3. Rig Upanishad
  4. Garbha Upanishad
4. The landmark textbook of women's health and disease published by Soranus of Ephesus was:
  1. De Morbis Mulierum
  2. De Humani Corporis Fabrica
  3. Historia Plantarum
  4. Hippocratic Corpus
5. The accurate description of human anatomy from dissection of cadavers was published by:
  1. Andreas Vesalius
  2. William Smellie
  3. Marcus Ulpius
  4. Agnocide
6. The first vaginal hysterectomy that was conducted successfully in modern times is credited to:
  1. Ephraim McDowell
  2. JCM (Conrad) Langenbeck
  3. Charles Clay
  4. James Marion Sims
7. Professor Henry Dale described the action of which commonly used drug?
  1. Methergin
  2. Prostaglandin F2 alpha
  3. Oxytocin
  4. Misoprostol
8. The following are considered as the pioneers of radical hysterectomy, except:
  1. Joe Vincent Meigs
  2. James Young Simpson
  3. Friedrich Schauta
  4. John Clark
9. All the following played a vital role in the development of the cervicovaginal smear technique for early detection of cervical cancer, except:
  1. Ernst Wertheim
  2. Herbert Taut
  3. Andromache (Mary) Mavroyeni
  4. George Papanicolaou
10. The first baby by the in vitro fertilization technique was born in:
  1. 1968
  2. 1975
  3. 1978
  4. 1982
1. b
2. c
3. d
4. a
5. a
6. b
7. c
8. b
9. a
10. c
Tripti Nagaria
“Extensive research has shown that no matter how knowledgeable a clinician might be, if he or she is not able to open good communication with the patient, he or she may be of no help”.
Healthcare system is dependent upon the effective communication between the healthcare provider and the receiver, i.e., the patient and the community. Communication should not be considered as simple interaction or process of exchange of information, it is an important and powerful tool in bringing about change in existing human behavior and attitude increasing the knowledge and acquiring skill.
“Communicate”, a Latin word from which the word communication is derived, means to share. Communication is defined as the process of transmission of information from one individual to another individual or group of people or from one organization to another by using any suitable medium like speaking, writing, or any other.
The key elements in the communication process (Fig. 1) are:1,2
  1. Sender (source of generation of information)
  2. Receiver (recipient of information)
  3. Message (content of information)
  4. Channel (medium of communication)
  5. Feedback (effect of communication)
The sender or the communicator is the one who originates the message or information and sends it to other individual/individuals or organization/organizations.
zoom view
Fig. 1: Key elements in the communication process.
11For effective communication sender must have the knowledge of:
  • Objective of communication—clearly defined
  • Receiver—about their type, interest and abilities
  • Message—must have accurate, useful contents
  • Channel(s) of communication—medium of transmitting information written, spoken or otherwise
  • Professional limitations and abilities as sender.
Status and the knowledge of the communicator also influence the impact of the communication.
The receiver is the individual/organization or a group of the individuals/organizations whom the message is directed. The group can be homogeneous means a group having common interest or heterogeneous having varying interests. Communication of message in a homogeneous group is more effective as compared to heterogeneous one. The extent of comprehension of the message by the receiver depends on their receptivity or readiness to accept the message, prior knowledge about the topic and the relationship and trust that exists between sender and receiver.
It is the information the sender wishes to deliver to the receiver to understand, accept or act upon. It may be in form of words, spoken or written, in form of signs, symbols, audio or video, drawing, pictures, placards.
  • The key to success of communication is transmission of right message at right time to right audience in right way.
Channels of Communication
Channel is the media of communication between the sender and the receiver(s).
Media systems which can be used:
  1. For interpersonal communication:
    • Verbal both oral and written, or sign language
  2. For mass communication:
    • Television (TV), radio, printed media, etc.
    • Traditional folk media—folk dances, drama, singing, Nautanki, etc.
Considering the advantages and limitations of every channel, many a time one may use more than one medium for effective communication. Selection of the right media whether oral or written is very important for effective delivery of message. It depends upon several factors like:
  • Urgency
  • Need of feedback
  • Need of documentation or a permanent record
  • Complexity of message
  • In case of organization—whether the message will be delivered to individual/s or department/s of the organization or outside the organization
  • The skill of the receiver to understand the verbal or written communication
  • The audience whether a person, a small group or large group or population.
Feedback is the response of the receiver to the message transmitted. It may be again verbal or nonverbal like a spoken or written comment, a gesture, facial expression, nonverbal behavior, a smile, or some other action. “No response is also a form of response”.
Feedback is of paramount importance in communication as it allows evaluation of the effectiveness of the message and provides an opportunity to modify or clarify a misunderstood message, rectify the transmission errors, and make it acceptable. Feedback can be immediate as in interpersonal communication or can take some time as in mass media communication. Feedback is the key component of the communication to confirm that the receiver has interpreted the message correctly.
In healthcare settings, all these elements of the communication are affected by various factors particularly in an understaffed setting.
In such setup, the healthcare personnel have to do many works or perform duties at multiple sites. The pressure of working result in fatigue, less concentration, distractions, lapses in memory, stress, frustrations, etc., these can lead to errors, misunderstanding of messages, miscommunication, poorer responses and can affect the patient care.
In a healthcare system, knowledge of the processes of communication and communication skill play a very vital role. From the very first contact with, till discharge from the health- care system the patient and their relative/caretakers need to know various information essential for the management of the case, may it be information about disease, diagnosis, how to and where to get admitted, for making decision for various intervention, medicines, follow-up, etc. Thus, interaction with various persons of different cadres in the system is a routine in hospital setting. Different patients and relatives have different ability to transmit, receive and understand the message, as well as to react based upon their age, literacy skills, language, social and cultural background, disabilities, etc.
Similarly in the system not all the personnel have similar efficiencies in communication and various factors apart from above mentioned other factors like pressure of the work, multitasking, background noises, interruptions, fatigue, lack of sleep, etc., may affect their ability.
Discharge summary or transfer tickets at the time of shifting to another care system is another very essential and important written document which conveys the essential features of condition of intervention done and the treatment and 12follow-up instructions. Improperly made or communicated notes can lead to errors in the further understanding and management of the patient.
At various points of contact and stages of care, the communication method may change in terms of senders, messages need to be given, means or channels used, receivers may be patient himself or family members and expected feedback. Therefore, ultimate outcome depends upon both how efficiently message is conveyed as well how efficiently the receiver has perceived and understood it. Thus, a deep understanding and knowledge of communication skill is essential for success and failure of the system.
Broad categories of communication are:
  1. One-way communication (Didactic method)
  2. Two-way communication (Socratic method)
The characteristics of two methods are as shown in Table 1.
Communication can also be categorized as follows (Table 2):
  1. Based on communication channels
  2. Based on style and purpose
Verbal Communication
Verbal literally means spoken, oral, vocal or unwritten; therefore, verbal communication in general gives an impression of spoken communication. However, in communication, verbal includes use of language and words in both spoken and written forms and for those who are with hearing impairment sign language as well.
TABLE 1   Characteristics of one-way and two-way communication.
One-way communication
Two-way communication
Flow of transmission of information
One-way from sender to receiver
Two-way both take part
Active participation of receiver
Feedback generation
Place for clarification
Passive, authoritative
Active, democrative
Influence on human behavior
Complex message
Difficult to transmit
Easier, more effective
Classroom lecture, notice, advertisement
Discussion, interpersonal communication
TABLE 2   Categories of communication.
Based on communication channel
Based on style and purpose
  • Oral
    • Face-to-face
    • Distance
Examples of two methods are as shown in Table 3.
Nonverbal Communication
Nonverbal communication is “Wordless communication”, where no words whether spoken or written are used still it is a powerful tool of conveying message and feedback. It is often complementary to verbal communication and if used properly aids to its effectiveness. It usually expresses the mood, opinion, reluctance, and reaction to the message received.
Some of the modes of nonverbal communication are:
  • Physical nonverbal communication: Bodily physical movements can be most expressive observable way of nonverbal communication. In day-to-day practices and routine life, it comprises more than half of the communication. Some of the common examples are facial expressions, body language, hand movements, gestures, posture, walk, touch, gaze, etc. these are the common way of expressing reactions to the messages received.
  • Paralanguage: Nonverbal aids to spoken communication are by changes in the tone, pitch and quality of voice, and style of speaking. It conveys the mood of the sender as well as the receiver, reaction of the receiver, expresses the emotions in more or less 36% of communications are supported or aided with these paralanguages to convey the feelings.
    Major differences between verbal and nonverbal communication are as shown in Table 4.
    Nonverbal communication by patient: Nonverbal communication plays a vital role in the healthcare delivery system as it may be more important feedback from the patient than any verbal one. It provides a reliable indicator about the condition of the patient.
TABLE 3   Examples of verbal communication.
Exchange of information in written form
Exchange in spoken words
Direct, face-to-face
Indirect, distance
  • Emails
  • Letters
  • Reports
  • Consent
  • Discharge papers
  • Posters, flyers
  • Documents
  • Handbooks
  • Posts on social media, etc.
  • Face-to-face communication, Counseling
  • Personal communication
  • Presentation
  • Meetings
  • Lectures
  • Discussions
  • Conferences
  • Interviews
  • Telephonic conversation
  • Chat talk
  • Voice message
TABLE 4   Differences between verbal and nonverbal communication.
Verbal communication
Nonverbal communication
Based upon
Use of language, words
Use of signs, body language, and others
Chances of confusion in understanding the message
Very few as language is used
High as no language is used
Time taken in interchanging the message between the receiver and sender
Fast hence feedback is also rapid
Takes time to understand hence slow
Location of both the parties
May or may not be at same location
Needed for effective communication
TABLE 5   Examples of nonverbal behavior.
Nonverbal behavior
Body language
  • Gestures
  • Facial expressions
  • Postures
  • Body orientations
  • Body proximity/distance
  • Eye contact
  • Mirroring
  • Remove the barriers (e.g., desks, keeping the mobiles off/silent
  • Sighs
  • Grunts
  • Groans
  • Voice volume
  • Voice pitch alteration
  • Voice fluency
  • Nervous giggles
  • While examining, interacting with the patient, observation of the nonverbal communication of like facial expression is informative. However, while examining a patient, one should watch for the comfort zone of the patient, sometimes closeness may disturb and make the patient uncomfortable.
  • Body language: Various body languages of the patient can express the emotional response like anger, depression, frustration, feeling good, greeting, etc., For example, avoiding of eye contact, silence, various gestures, hand movements, eye movements, clinching of jaw, fist, etc.
  • Paralanguage: Pauses, changes or variations in voices during communication again give important clue of the emotional status of the patient.
Some of the nonverbal behaviors are as shown in Table 5.
Both verbal and nonverbal forms of communication are complementary to each other. Whereas the verbal form is the face-to-face communication and better way of understanding the message, the nonverbal form satisfies the emotional understanding.
Other ways of nonverbal communication: Following are some of other ways particularly in group or mass communication.
  • Visual communication: Communication through visual aids like drawings, placards, tables, maps, charts, graphs, pictogram, poster presentations, illustrations, etc.
  • Esthetic communication: Various types of art forms like drawing, sketches, and paintings are also powerful means of transmitting the message.
  • Appearance: The appearance, clothes, and the color of the fabrics, etc., also have important impact on the reaction of audience.
Formal and Informal Communication
Written verbal communication using scientific and official language, observing systematic policies, and procedures is formal communication. In healthcare system, this form of communication is done with following objectives:
  • Patients’ education and counseling to ensure their safety
  • Information or documents on medical policies, rules and regulations, guidelines, notifications, publications, instructions, etc.
  • Formal records system and prescription, etc.
Informal communication is casual nonspecific or common communication between members of the organizations (gossips). However, health information internet has expanded this form of communication. Various healthcare-related advertisements and information are now available on health- care media. Exchange of information between patients and their healthcare providers related to patients’ illness is another example of it.
Both formal and informal communication play vital role in improving the quality of healthcare, patient safety, and behavior of patients.
Effective communication is one which end with transmission of message or feeling from the sender and perceived by the receiver.
There is a concept of “7Cs” or characteristics that must qualify the communicating activities and processes to make it effective (Box 1).
  1. Clear: The message being transmitted must be very clear and easily understandable with simple and short sentences. In written documentation, one should use active voice over the passive voice and if multiple messages are to be conveyed separate bulleted points must be used.
  2. Concise: Any attention span is just a few minutes long; therefore, to be effective the message should be short and concise.
  3. Concrete: Whatever message or information or data is present in the communication, it should be suitably backed up. A tangible argument is always easy to understand.
  4. Coherent: For written documentation, coherence is very essential. It should be well planned, the information should be in sequential manner, follow each other. The main ideas should be well-differentiated.
  5. Courteous: The information or the communication whether written or verbal must not hurt the feelings of 14the receiver, it should be respectful, polite, thoughtful, with proper care and kindness. Language used must not be offensive, insensitive or awful to the receiver.
  6. Consideration: For effective communication, one must get connected to and involved with the target audience. Hence, the presenter must know/assess the background knowledge on the topic, level of literacy, age, and interests of the receiver/s before start of communication.
  7. Consistent: Consistency in the information given adds to clarity of communication. Various statements or facts must be systematically presented to avoid any confusion.
Any parameter that limits the purpose or channel of communication between the transmitter and the receiver is a barrier to communication. It may limit or reduce the ease at which one communicates and the intended message will often be disturbed and distorted leading to a condition of misunderstanding and failure of communication.
Although the barriers to effective communication may be different for different situations, the following are some of the main barriers as shown in Table 6.
  1. IEC—information, education, and communication—aims to generate specific awareness in targeted population.
  2. BCC—behavior change communication—aims to generate awareness in the targeted population with an aim to change the behavior.
  3. SBCC—social behavior change communication—aims to change the social condition and individual behavior.
Health education can be defined as the principle by which individuals and groups of people learn to behave in a manner conducive to the promotion, maintenance, or restoration of health, e.g., information and awareness about various national programs, immunization program, antenatal intranatal and postnatal care services, family planning services, safe abortion services, breastfeeding awareness, cancer awareness, etc.
This can be done using all the methods of communication:
  1. Individual method: Counseling and interview
  2. Group method: Group discussion, role play, brainstorming, workshop/seminar, demonstration, mini-lecture, symposium. problem solving, panel discussion, field trip/educational tour, etc.
  3. Mass media method: Using visual aids—posters, video, paintings, etc.
TABLE 6   Barriers of communication.
S. No.
Factors causing difficulties in communication
Linguistic barriers
Difference in language or dialects between the providers and receiver
Psychological barriers
Mental issues like fear, speech disorder, depression, etc.
Emotional barrier
Emotional IQ of persons, anger, frustration, humor, etc.
Physical barrier
Noise, closed doors, faulty equipment used for communication, etc.
Cultural barriers
Differences in cultural values of the society
Attitude barriers
Ego, inconsiderate behavior, etc.
Perception barrier
Differences in ability to perceive, understand the messages, literacy, previous knowledge, age, prolong ill health, etc.
Physiological barrier
Disorder like shrillness of voice, dyslexia, etc.
Socioreligious barrier
Woman, transgender may face difficulty in certain community
Counseling is a bidirectional interpersonal communication to analyze the feelings, opinion, believes, thoughts, and problems of a person and helps him to take sensible decision. Herein two unrelated persons meet to discuss and find out the ways to conquer the crisis or problem in an atmosphere which is supportive to let the person define the situation, build up self-confidence and respect and readiness to bring about lifestyle modifications to reduce the brunt of the problem on himself and on their close ones.
Counseling is not about taking the decision for the person/client and also not about judging, cross-examining, disagreeing with what the client is speaking or instructing the client but it is a process by which the client is conversed in such a way that he himself becomes confident enough to take suitable decision, it can only be done when the counselor though working very closely is not emotionally attached to the client. This approach aims to help the clients in developing 15the skills to solve the problems and to cope up better with the situations they are facing. This engrosses the individual to handle with their emotions and feelings and to help them make positive choices and decisions.
  1. Focus and attention: While receiving or transmitting information, focus and attention are very important. Any mislaid communication could be unsuccessful as if one loses attention, important part of the information may be overlooked or failed to notice altogether.
    Attending: It refers to the way the counselor is connected to the patient both physically and psychologically, i.e., how does he position himself to listen to the client carefully. Gerard Egan defined SOLER as a part of his “Skilled Helper” staged approach to counseling. It is a nonverbal listening process used in communication and is stand for:
    • S: Squarely face your patient
    • O: Open posture
    • L: Lean toward the patient
    • E: Eye contact with the patient
    • R: Try to be Relaxed or natural with the patient
  2. Listening for understanding: It refers to capturing and understanding the message, the patient wants to give irrespective of the way verbal or nonverbal.
    Four skills are involved in active listening:
    1. Listening to understand the verbal message of the client
    2. Listening to and interpreting the nonverbal message of the client such as bodily posture, gestures, groaning, facial expression, voice-related behavior, psychological reactions, general appearance, etc.
    3. Listening to and considering the client in perspective of her social background
    4. Listening with empathy.
  3. Basic empathy: Basic empathy involves active listening skill of the counselor to appreciate and consider the concerns of clients as best as he can. The understanding should then be communicated back to the clients in such a manner that help them to comprehend themselves more fully and act thoughtful. In other words, it is the skill to be acquainted with and acknowledge the reaction or emotions of another person with experiencing those same emotions. These feelings then must be communicated to the client in either verbal or nonverbal way.
  4. Questioning: It makes the counselor to get more issues from the clients. It also helps keeping the client more focused on main issues describing at large. Care must be taken to ask open-ended questions to let client describe the problem.
  5. Use silence effectively; do not interrupt unless necessary.
  6. Reflection and echoing: The provider observes the clients emotions and reflects them back. This helps provider to check whether his/her observations are correct. It also reflects the empathy and respect toward clients feeling.
  7. Praise and encouragement: The provider uses gestures and words to encourage and motivate the client and ensure his/her approval.
  8. Give information to the client clearly.
  9. Being nonjudgmental
  10. Emotional awareness and control: Remain emotionally stable to accept or reject any message with the intention, it is being relayed.
  11. Summarizing and paraphrasing: At the end, the counselor must summarize what the client had described; it provides an opportunity to the client to clarify.
The counseling is intended to help the patient to understand and develop the capability to cope up with his or her condition/disease, so as to promote a better quality of life.
Success of integrated healthcare delivery system to provide quality care to the patients and good outcome is founded in effective communication. Apart from providing better working environment with increased job satisfaction, it is the key to better patient outcomes with higher rates of patient satisfaction and continuation of treatment and reduced adverse events, hospital stay, and readmission rates.38 Several researchers have observed communication failure as the main factor contributing to the just the contrary outcomes.915
There are many models of communication and every health- care provider has his or her own style. Certain principles from different sources may be followed for effective communication as discussed here.
In Outpatient Department
From the very first contact to start of the treatment by the patient communication is the constant and most essential aspect of the medical practice involved right from getting the history of illness to explaining the treatment plan. Effective communication not only builds up good physician patient relationship but also leaves therapeutic effect on the patient.3
Steps to be followed:
  1. Greet the patient and know the problem he/she had
  2. Interview the patient:16
    • Focus and attention
    • Discover the understanding and knowledge the patient is already having about her illness
    • Evaluate or assess what does she want to know, before starting to inform
    • Be empathetic16
    • Give information slowly
    • Keep it simple
    • Tell the truth
    • Observe nonverbal behavior of patient
    • Be prepared for reaction
  3. Closing:
    • Use name of patient
    • Make positive statement.
A number of factors may affect the outcome like a busy outpatient department (OPD), short of time, noises, multitasking situation, mobile phone, etc. only by careful and effective handling of barriers and following principles of effective communication a trust and rapport can be build up.
During Transition of Care
Throughout the continuum of care, patients need to be transferred to different locations of varying levels, and to various healthcare providers for management as their condition demands, this needs movements of patients and their family members and/caretakers to different places within and sometimes to different hospitals. It involves multiple other persons too like medical, paramedical, and ancillary staff of healthcare delivery system.17 As with this transfer or relocation of the patient, the healthcare providers, decision taker, and the setup changes, a clear communication of the patient status regarding disease is necessary to make sure the quality of care.18 For effective transition, care apt and precise communication of information between providers, patients, and family caregivers are decisive. Any failure in execution of this safety measure leads to uncertainty about the care the patient is receiving, therefore, delay in care, improper monitoring, roughly one-half of all hospital-related medication errors and one-fifth of all adverse drug events, adverse outcomes, rehospitalization, and increased health- care expenditures.3,1921
Inadequate Handovers
During hospital stay, the patient has to come across many medical and paramedical staff in each shift of duty, intradepartmental or interdepartmental shifting to different location, for consultations, checkups, investigations and interventions, discharge, etc. For continuity of care and safety of patient during these shifting and change of heathcare providers, proper handovers are of paramount importance.22 Effective communication is therefore fundamental to safe and effective patient care.23 Failure of proper communication is identified as the one of the main root causes of serious medical errors.24 Penalty of such failure during handovers is in the form of medication errors, erroneous patient plans, delay in discharge or transfer to critical care, or/and repetitive tests among others.25
Lack of proper communication can occur at multiple levels; between physicians, physician and nurses, between nurses, between medical and paramedical staff, and between members of team involved in providing health care and the patients and the caretakers, relatives, etc. These can result in delay in start of treatment, wrong treatment, medication error and sometime wrong surgical invention and even fatalities.
This can be avoided by following measures during handing over:
  • Bedside handovers at all the levels should be done.
  • Properly written records should be provided.
  • Instructions must be clear.
  • Recent updates of the condition and treatment must be provided.
  • Using SBAR structured format26 to transfer the information.
    S—Situation: Why the information is being communicated? What updating the patient's condition, clarifying orders, alerting regarding emergency developed, etc.
    B—Background: What is the background information? (History or complaints or diagnosis with which patient was admitted/referred, treatment being given, change in condition of case, any new development of sign or symptom or emergency).
    A—Assessment: What is the assessment of problem at that moment of time? (Clinical examination finding) what appears to be the problem based upon clinical examination finding?
    R—Recommendation: What is needed to be done for solving the problem at that moment of time? How should the problem be corrected?
The use of SBAR tool in clinical setting has been endorsed by many healthcare organizations including WHO for improving the verbal communication among healthcare providers for handover.2731
I-PASS is another strong tool for communication for handovers during shift change and other transition care by healthcare providers, physician and nursing staff, to cut down the miscommunication and adverse outcomes. I-PASS is a mnemonic for: Illness severity (I), Patient summary (P), Action list (A), Situation awareness and contingency planning (S), and Synthesis by receiver (S).32 Facilities can adapt to ensure all the following information is communicated when providers perform handoffs (Table 7).
Inadequate Discharge
In a meta-analysis, Kripalani et al. observed discharge summaries often lacked important information such as main diagnosis (13–17.5%), diagnostic test results (missing from 33 to 63%), treatment or hospital course (7–22%), discharge medications (2–40%), test results pending at discharge (65%), patient or family counseling (90–92%), and follow-up plans (2–43%).33
To avoid this, few points should be kept in mind:
  • Discharge must be well-planned.
  • Computer-generated discharge summaries or standardized format must be used to emphasize the most important information to improve the quality of documents.17
TABLE 7   I-PASS tool for handover.
Illness severity
Current status of the patient:
OK/under observation/stable/unstable/to be discharged
Patient summary
At admission:
  • History, physical finding, test results
  • During the course of stay in the hospital
  • Ongoing assessment
  • Plan for further management
Action list
To do list—includes:
  • Actions to complete, e.g., diagnostic tests, consultations, procedures
  • Timeline and ownership
Situational awareness and contingency planning
  • Know what is going on and
  • Plan for what might happen, e.g., if the condition deteriorates, what is to be done immediately to address the change
(by the receiver)
  • The receiver summarizes what was heard
  • Clarifies any doubt, asks questions
  • Repeats the key actions/to do list
  • Sufficient time must be given to explain the contents of discharge summary, i.e., about the condition of the patient at the time of discharge, plan for follow-up and treatment in simple language in a way which is easily understandable and to make sure that the patient and their relatives have understood.
  • “5Ds of discharge” is one important tool which can be stressed in communication at the time of discharge to make sure the patient understands the information given and to do list.34 Following are the elements of 5Ds—Diagnosis, Drugs, Diet, Doctor follow-up plan, and Directions for any emergent situation (Table 8).
Handling Difficult Patient
Many a times certain difficulties to handle patients are encountered by healthcare providers, if not properly handled frustrations are likely to develop in both the parties.
Prevention of difficult interaction is best approach.
  • Recognize and concentrate on the psychological issues of the patient.
  • Listen to them with great attention and empathy as the feeling that “they are not heard” or “they are not worth” is the greatest cause of dissatisfaction of most of the patients.
  • Body language should be appropriate, should not be a cause of displeasure to patient.
  • Be careful of your own emotional state.
If encounter becomes tense, follow the following points:
  • Remain professional
  • Do not let your emotion overcome you
  • Active listening with summarizing
  • Acknowledging the emotions they are expressing.16
TABLE 8   5Ds of discharge.
Points to be discussed and ensured
Why was he admitted and given care?
Medicines—need for taking them
How to take—dose, route, time, in relation to meals. etc.
Any dietary restriction, consultation with nutrition specialist if suggested
Doctor follow-up
Plan for next visit/s, name of doctor and place where to visit for further continuum of care
  • Any other direction for achieving optimal health, e.g., exercise
  • Warning signs of urgency/emergency
  • If emergency arise whom to contact and/where to report for care
Special care and attention is required while communicating with seriously ill patients and to improve it various principles have been recommended, as follows:35
  1. Before starting the interaction specific to her illness, spend a few moments giving the patient completely focused attention.
  2. Start with what the patient wants to discuss or know.
  3. Observe and follow the emotional feedback from the patient.
  4. Move the conversation forward slowly, one step at a time.
  5. Express empathy overtly.
  6. Start with positive information like what can be done before informing what cannot be.
  7. Start with ultimate big goals before talking about specific medical interventions.
Age-related Challenges
There are particularly unique challenges associated with communicating with extremes of age, adolescents as well as elderly people.
Communication with Adolescent
Adolescents may get engage in high-risk behavior and require medical advices or care. However, to get the information from them is not always easy as they are afraid of being assessed.
  1. Greet them
  2. Break the ice by asking few general questions not related to health
  3. Give privacy
  4. Avoid distractions while interactions
  5. Listen with concentration, observe, and understand the nonverbal communications of the patient
  6. Allow her to speak, too many interruptions may let them feel being judged
  7. Mind your body language while interacting
  8. Show concern
  9. Give information in simple language, allow questioning.18
If given appropriate friendly atmosphere, appreciated as adult and opportunity to discuss, they may disclose their information. Confidentiality is the foundation of building up of healthy relationship with youth. With proper communication/counseling, adolescents can be helped to take sensible decision to overcome the situations or the problems they are facing.
At the other extreme end of the age range, the elderly patients also present challenges in different ways. Multiple age-related and psychological issues make the communications challenging for the healthcare workers. Physical disabilities like visual and hearing impairment, medical disorder or comorbidities and medications for chronic disease, along with memory lapses and lack of psychological, social support put them at higher risk for adverse outcome, suboptimal care and medications particularly at the transition of care.
  • Spare more time for older patients; do not appear hurried or uninterested36
  • Avoid or reduce visual and auditory distractions37,38
  • Assess and compensate for any visual or auditory impairment
  • Ascertain respect from the beginning
  • Maintain eye contact4
  • Begin conversation with questions about family members or other interests rather than illness to decrease the anxiety
  • Go slow—speak slowly, in a clear and loud voice and give patient sufficient time to understand the information
  • Do not interrupt—listen till she completes
  • Use simple, common words.
  • Summarize repeatedly the most salient points
  • Discuss only one topic at a time, inform the patients at the time of changing the subject
  • Give clue to help her understand what is being said—such as brief pause, speaking a little louder, indicating or making gestures to make her understand topic to be discussed, asking questions to lead to the topic, etc.
  • Think about use of alternatives to printed materials for visually impaired patients or patients with low literacy skill—such as vocal instructions, e.g., recorded instructions, visual large pictures or diagrams, or other aids.
Cultural Difference
It must be addressed while providing health care. Providing efficient and effective care requires having conversations in which the provider and patient both understand the meaning of words, concepts, and metaphors. Cultural differences also affect the working relationships between providers, as physicians and nurses, for example, sometimes have different value systems relating to how patients are cared for and treated.
Errors in Medical Orders and Test Results
Errors in medication in healthcare system can also be due to the verbal communication of the orders and test reports to the comembers of the team, patient or their caretakers, especially over phone.
  • Difficulty can arise in understanding the message or the order due to difference in language, tone of voice and pronunciation or articulations.
  • Another error prone verbal communication is giving instruction about sound alike drug name, number as this may affect the accuracy of the order and thereby the end result.
  • Distracters like background noise, any break in continuity of speech due to other involvement, and use of unusual or new drug names and terminology often accentuate the magnitude the problem.
  • Verbal and vague orders often end up with mismanagement, delay in treatment, over treatment or even omissions of medication treatment jeopardizing the patient safety.
To avoid this type of error, the healthcare system should develop a standardized protocol of communicating the order and test reports. Orders, prescription, reports should be properly written rather than verbally communicated. Health- care providers must use of specific rather than uncommon terms for the intervention.39
During Treatment/Intervention
Communication failures during health care can be of multiple types viz. too late to be effective, not communicated to all the members of the team involved in the particular health care, incomplete and inaccurate transmission of information and not ending with fulfillment of the purpose until emergent situation arises.38 Such failures are responsible for poor outcome and need to be addressed.
Also, throughout the continuum of care of a patient a number of procedures are needed and carried out which require adequate and effective communication to explain the procedure, need and related risk and benefits. Any deficient communication or no communication can end up in patients or relative's dissatisfaction and professional liability. Therefore, a defined procedure must be developed by every hospital to obtain an informed patient consent for various procedures being carried out during the inpatient care like any high-risk treatment, blood or blood product transfusion, surgical intervention, anesthesia, investigative procedures requiring anesthesia or sedation or carrying inherent risk, etc., in a manner and language the patient can understand.
Errors likely to Occur during Surgical Procedure in Operation Theater
Analysis of 421 communication events in the operating room (OR) found communication failures in approximately 30% of team exchanges; one-third of these jeopardized patient safety by increasing cognitive load, interrupting routine, and increasing tension in the OR setting.40
The most dreaded adverse event that can occur is a wrong operation carried out on a wrong person or wrong site. To prevent errors during surgery (wrong site, procedure, and 19person), a universal protocol is designed.41 One must check for the following before start of the surgery.
  • Preprocedure verification process of the correct patient, procedure, and site
  • Surgical site marking
  • Ensuring the availability of all relevant documents and studies of the patients
  • Images are properly labeled and displayed
  • Verifying the availability of any required blood products grouped and crossed matched
  • Special medical equipment if needed are present42
  • To ascertain the site, patient must be actively involved in marking whenever possible and having the mark be visible after the patient is prepared and draped.
Obtaining a Consent for Surgical Treatment
  • Obtaining an informed consent for surgical treatment is the need and also a challenge for the treating doctor/surgeon. It is not merely asking the patient and/their relatives sign the form. It requires surgeon to have good rapport with the patient and their relative or their caretakers so that necessary information can be transmitted to help them to decide to undergo surgical treatment. There should be clarity of explanation that leads to informed and deliberate consent.
  • There must be a discussion on the various options of the management.
  • Outcomes if the patient does not opt for surgery.
  • Discussion on the need of procedure, the expected benefits, chances of success or failure, risks involved and complications that may develop.
  • Need of additional management should the need arise.
  • Type of anesthesia and related information.
  • Follow-up plans and further additional management if needed.
  • Surgeons involved in the intervention.
  • The patient and relative/caretaker should be given time to think over, discuss and to ask any question or more information if they want.
  • Consequences of nonoperative alternatives should also be explained.
  • Consent should be in the language they understand.
  • It must be read, understood and signed by the patient, relative or guardian and witnessed with a mention of time.
Consent should be looked as a procedure of shared decision making with patient and their relative/guardian. Informed consent as the one where the treating physician has explained the patient and their relative and they understood diagnosis, treatment options, the risk and benefits involved therein, chances of success and failure of the procedure, immediate and delayed complication if any and also of no treatment if they opt for and finally came to the decision.43
Thus, obtaining informed consent challenges professional competence. It is a time taking process of communication involving education, patient sympathetic listening and satisfying the queries of the patient, relatives/caregivers that continues through the continuum of care. It requires good patient-surgeon communication and lack of which may lead to professional liability.44
Effective communication and counseling play a very vital role in improving the health outcomes in healthcare system resulting in better management, patients’ satisfaction, and higher chances of continuation of treatment and follow up and building up of trust in the system. It is the responsibility of not only the doctors and nursing staff but of every member of the team involved in the management of patient including the paramedical and the ancillary staff to develop the skill of effective communication and counseling for achieving the ultimate goal of health care.
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  1. 20 Baggs JG, Schmitt MH, Mushlin AI, Mitchell PH, Eldredge DH, Oakes D, et al. Association between nurse-physician collaboration and patient outcomes in three intensive care units. Crit Care Med. 1999;27:1991–8.
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  1. Zwarenstein M, Reeves S. Working together but apart: barriers and routes to nurse—physician collaboration. Jt Comm J Qual Improv. 2002;28:242–7.
  1. Fagin C. Collaboration between nurses and physician: no longer a choice. Acad Med. 1992;67:295–303.
  1. Woolf SH, Kuzel AJ, Dovey SM, Phillips RL Jr. A string of mistakes: the important of cascade analysis in describing, counting, and preventing medical errors. Ann Fam Med. 2004; 2(4):317–26.
  1. Balogh EP, Miller BT, Ball JR. Improving Diagnosis in Health Care. Washington (DC): National Academies Press (US);  2015.
  1. Larson E. The impact of physician-nurse interaction on patient care. Holist Nurs Prac. 1999;13:38–47.
  1. Sexton J, Thomas EJ, Helmreich RL. Error, stress, and teamwork in medicine and aviation: cross sectional surveys. Br Med J. 2000;320:745–9.
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  1. American College of Clinical Pharmacy, Kirwin J, Canales AE, Bentley ML, Bungay K, Chan T, et al. Process indicators of quality clinical pharmacy services during transitions of care. Pharmacotherapy. 2012;32(11):e338–47.
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1. What are the characteristics of effective communications?
2. Discuss the barriers to good communication and modalities to overcome them.
1. What are the key elements of the communication process.
2. What are the broad methods of communication?
3. What are the characteristics of one-way and two-way communications?
4. What are the differences between verbal and nonverbal communication?
1. Sign language is an example of:
  1. Nonverbal communication
  2. Verbal communication
  3. Formal communication
  4. Paralanguage
  5. None of the above
2. Feedback allows the sender:
  1. To evaluate the effectiveness of message
  2. To clarify the message
  3. To confirm whether it is interpreted correctly by the receiver
  4. To rectify transmission error
  5. All of the above
3. SOLER is a:
  1. Method of questioning
  2. Method of listening and attending the patient
  3. Method of giving information
  4. Method of judging the patient
  5. Method of taking informed consent
4. In counseling, all are true, except:
  1. Listening
  2. Summarizing
  3. Being judgmental
  4. Questioning
  5. Giving information
5. Effective communication is helpful in all, except:
  1. Reducing readmission rate
  2. Reducing hospital stay
  3. Reducing patient satisfaction
  4. Reducing unnecessary investigation
  5. Reducing adverse events
6. Transition of care is movement of patient between:
  1. One location to another in same hospital
  2. One hospital to another
  3. Health care providers
  4. Hospital and home setting at the time of discharge
  5. All of the above
7. SBAR structured format comprises of:
  1. Safety, background, assessment, recommendation
  2. Situation, background, assessment, rationale
  3. Safety, background, awareness, recommendation
  4. Situation, background, assessment, recommendation
  5. Situation, barriers, awareness, review
8. 5Ds are used for:
  1. Disabilities
  2. Diseases
  3. Difficulties
  4. Discharge
  5. Dilemmas
9. While communicating with adolescents which one is most important:
  1. Confidentiality
  2. Concise
  3. Consistency
  4. Clarity
  5. None of the above
10. Current evidences suggest for better management of patient with effective communication skill, the approach should be:
  1. Disease-centered approach
  2. Treatment-centered approach
  3. Outcome-centered approach
  4. Patient-centered approach
  5. None of the above
11. Informed consent for surgery should include:
  1. Purpose of intervention
  2. Expected benefit
  3. Follow-up plans
  4. Complications
  5. All of the above
12. Communication is a responsibility of:
  1. Doctors and nurses only
  2. Doctors only
  3. Nurses only
  4. Paramedical staff and doctors only
  5. Whole health care team
13. All except one are not an example of verbal communication:
  1. Informed consent
  2. Discharge ticket
  3. Hospital policy document
  4. Groan
  5. History taking
14. Medication error can occur:
  1. Sound alike drug
  2. Sound like number
  3. Inadequate handovers
  4. Illegible handwriting
  5. All of the above
15. IEC means:
  1. Information, education, and communication
  2. Information, education, and compliance
  3. In house, education center
  4. Individual education chart
  5. None of the above
1. a
2. e
3. b
4. c
5. c
6. e
7. d
8. d
9. a
10. d
11. e
12. e
13. d
14. e
15. a
Anahita Chauhan, Madhva Prasad S
Medical textbooks usually begin with the disclaimer “Medicine is an ever-changing science, with new information being added on a regular basis. The reader is advised to verify the validity of the information provided in light of constant changes.” This oft-neglected guidance is extremely important as there is now a steady and sure movement away from traditional repositories of knowledge (such as physical/paper books and journals), toward an increasingly electronic interface. Textbooks undergo revisions and updating once in a few years, and serve only as a starting point for information; hence online resources are relied upon and encouraged by many institutions. In-person seminars are also being replaced by internet-based webinars, as are in-patient consultations. These changes in our understanding of the subject and our practice can be overwhelming for the student and the reader.
This chapter aims to decode EBM and stimulate the student to pose the inquisitive question “Is this evidence-based?” while reading any medical text. Exciting changes occurring at the intersection between information technology and medicine are also addressed in Medical Informatics. We hope this chapter provides the student “a lens” through which the rest of this textbook can be viewed.
Evidence-based medicine has been defined as “the use of scientific methods to organize and apply current data to improve health care decisions. Thus, the best available science is combined with the healthcare professional's clinical experience and the patient's values to arrive at the best medical decision for the patient”.1
Evidence-based medicine can also be defined as “the conscientious, explicit, judicious and reasonable use of modern, best evidence in making decisions about the care of individual patients”.2
The three key elements of an EBM approach are shown in Figure 1.
  1. Good clinical expertise: This refers to “what the clinician knows”. This mainly relates to the competency of each individual clinician, which is irreplaceable and is learnt over years of practice.
  2. Patient preferences and values: This refers to “what the patient is desirous of”. Consenting to the type of the treatment forms the crux of the matter.
    While these two concepts are being learned constantly, the third concept is a relatively new one.
  3. Best available evidence from research: This is the major addition to the field and refers to how the healthcare provider can utilize constantly evolving data and information to best serve the patient.
zoom view
Fig. 1: Evidence-based medicine (EBM) triad.
The term “evidence-based medicine” was first introduced by the pioneering clinician epidemiologist David Sackett, at the McMaster Medical School, Canada.3 It was a gradual movement which attempted to increase the quality of clinical research and help in better decision making. For most of the 20th century, medicine “trusted in the experts”. The EBM movement helped in changing the mindset toward “trust in the numbers”. The biggest change is the introduction of systematic reviews, with the ability to identify individual studies which are similar and of good quality, and interpret them after combining them. Thus, the conclusions are drawn from a larger number.
Levels of Evidence
The level of evidence, which is now a standard nomenclature, is available as an essential information in most guideline documents/textbooks and is summarized in Table 1.4
There is a clear hierarchy among the different types of studies (Fig. 2) and their corresponding levels of EBM. Individual case reports and case series of a few patients do not help in drawing any particular conclusions. These form the bottom of the pyramid. Next are case-control studies and cohort studies. While they answer questions pertaining to the epidemiology, risk factors and associations of a condition, they cannot provide specific clinical guidance, and may in fact, be biased in study design and methodology. A correctly conducted randomized controlled trial (RCT) is the gold standard of EBM. A group of patients having a particular clinical condition are subjected to two different management modalities, in a systematic manner. The data of the clinical outcomes are analyzed by an impartial observer, 23and the results of such a study are considered to be “Level 1 evidence” (Table 1).
TABLE 1   Levels of evidence.
Meta-analysis of high quality, systematic reviews of RCTs or RCTs with a very low risk of bias
  • Properly-conducted RCTs when repeated and combined in meta-analysis yield the strongest results
  • The properly-conducted RCT is considered the gold standard in medicine
Meta-analysis, systematic reviews of RCTs or RCTs with a low risk of bias
Meta-analysis, systematic reviews of RCTs or RCTs with a high risk of bias
Level 2++
High-quality systematic reviews of case-control or cohort studies or high-quality case-control or cohort studies with a very low risk of confounding, bias or chance and a high probability that the relationship is causal
  • Introduction of bias is possible when there is no randomization
  • Some topics in medicine cannot be addressed ethically or effectively by randomization (inability to take a control group)
Level 2+
Well-conducted case-control or cohort studies with a low risk of confounding, bias or chance and a moderate probability that the relationship is causal
Level 2−
Case-control or cohort studies with a high risk of confounding, bias or chance and a significant risk that the relationship is not causal
Level 3
Nonanalytical; nonexperimental study such as case-series. A poorly-designed case-control or cohort study also features here
Control groups or cohorts are not possible in some rare diseases or occasional occurrences
Level 4
Expert opinion from respected authorities on the subject
Extreme level of inter-expert heterogeneity is possible
zoom view
Fig. 2: Evidence pyramid (types of research).
A nonstatistical collation of the results of various RCTs presented as evidence summaries and clinical guidelines are inferior to systematic reviews. Meta-analysis and systematic reviews, which bring all available information on the subject together, form the apex of the pyramid or the highest level of evidence.
Grading of Recommendations
In any particular subject, each recommendation is assigned a particular grade based on the level of evidence available. The higher the grade of recommendation, the stronger is the support given by the body of evidence available. Grading of evidence is shown in Table 2. Various international bodies and institutions develop guidelines systematically using standardized methodology after reviewing all the available literature. For example, the Royal College of Obstetricians and Gynaecologists (RCOG) defines “clinical guidelines” as “systematically developed statements which assist clinicians and patients in making decisions about appropriate treatment for specific conditions”. Details about how these guidelines are developed and kept transparent are also published.24
Effective Utilization of Evidence-based Medicine
Incorporating EBM is a lifelong process, which is self-directed, and is a problem-based approach while caring for one's patients. An effective method of utilizing EBM in practice is summarized in Figure 3. Apart from the clinical skills that are acquired to manage patients, the EBM movement requires the clinician to be able to:
  • Use summary of evidence in clinical practice
  • Help in development and updating of systematic reviews or guidelines in their specific areas
  • Enrol patients in studies to eventually help in generation of better evidence.
TABLE 2   Grades of recommendation.
Grade of recommendation
At least one meta-analysis, systematic review or randomized controlled trial rated as 1++. A systematic review of RCTs or a group of evidence composed of studies rated as 1+. These should be applicable to the population concerned. There should be overall consistency of results
  • Evidence from studies which are 2++ with overall consistency of results. This should be applicable to the population concerned
  • Evidence extrapolated from studies ranked as 1++ or 1+
  • Evidence from studies which are 2+ with overall consistency of results. This should be applicable to the target population
  • Extrapolated evidence from studies rated as 2++
Evidence level 3 or 4; or extrapolated evidence from studies rated as 2+
Good practice point (GPP)
Recommended best practice based on the clinical experience of the guideline development group
zoom view
Fig. 3: Steps in utilizing evidence-based medicine.
Types of Questions Answered by Evidence-based Medicine
  • Therapy question: In pregnant women with hypertension of 160/110 mm Hg, is labetalol a better choice than nifedipine?
  • Prognosis question: Does the use of alpha methyldopa among preeclamptic women have any implication on postpartum psychosis?
  • Diagnosis question: Is 24-hour urine albumin mandatory to achieve a diagnosis of preeclampsia?
  • Harm question: Does preconceptional smoking increase the risk of development of preeclampsia?
It is advisable to fit any clinical question into a PICO (patient/population, intervention, comparison/control, and outcome) format, which is illustrated with examples in Table 3.5
Acquisition of Best Evidence
While textbooks form the best source of consolidated evidence, by the time they are published, medical science may already be outdated. Hence, an electronic search of available literature is the preferred method for the latest updated evidence. Cochrane review, disseminated by Cochrane Database, is a charitable independent group which focuses on systematically reviewing the available health care information and facilitating evidence-based health interventions. Scores of health care scientists and volunteers contribute to the evidence generation in an impartial manner. The motto of Cochrane, “Trusted Evidence, Informed Decisions, Better Health” is the embodiment of EBM. For any particular subject or intervention, a Cochrane review is considered equivalent to the highest possible level of evidence. Efficient and correct use of search engines to perform a literature search using resources such as PubMed, UpToDate, and ClinicalKey are essential skills which the clinician should learn early in his career.
Critical Appraisal of the Evidence
The ideal information should be valid, relevant, comprehensive, and user-friendly. Blindly trusting all published information is near-sighted; not all published material is of equal importance or value.
Ensuring the Correct Perspective of Evidence-based Medicine
The intention of clinical recommendations is not to “dictate” a singular course of treatment or management. However, these recommendations should be utilized after a critical evaluation with special reference to each individual patient's needs and resources. The clinician should exercise judgment and understanding of the limitations which prevail in their respective institution(s) and local population variations. It is important to explain to the patient the evidence-based rationale behind a particular treatment modality.625
TABLE 3   Constructing a question using the PICO format.
Alternative intervention?
To which group would this patient be described as belonging to?
Which treatment, test or other intervention is being considered for this patient/group
  • Is there an existing gold standard?
  • What other treatment or test exists or perhaps to doing nothing
What are the patient-oriented outcomes? Better survival? Better prognosis? Higher rate of cure? etc.
Patients with preeclampsia beyond 37 weeks of gestation
Induction of labor
Watchful expectancy
Occurrence of eclampsia/maternal morbidity/maternal mortality
Patients with polycystic ovary syndrome (PCOS) with infertility
Ovulation induction with letrozole
Ovulation induction with clomiphene
Documentation of ovulation, chemical pregnancy rate, clinical pregnancy rate, live birth
Patients with stage III epithelial ovarian cancer
Neoadjuvant chemotherapy followed by operative procedure
Operative procedure
Success at debulking, residual disease, 1-year survival, 5-year survival
Challenges in the Everyday Application of Evidence-based Medicine7
Inability to Subject Every Aspect of Medicine to an RCT
“If truth speaks for itself, why do you have to test it with the nontruth?”
Though RCT is the gold standard, no formal RCT has been conducted to prove the efficacy of Pap smear in preventing cancer cervix. Subjecting patients who have an open wound to an RCT comparing suturing and nonsuturing is never possible. Clinical medicine offers many such scenarios. It is absurd to say that the level of evidence and grade of recommendation regarding such “obvious” clinical practice are “poor”.
Statistical Jingo, Mathematical Absurdity, and Extrapolative Fallacies
“I chose to study biology and medicine, because I knew I was weak in Math.”
“If there is indeed a difference between the two groups, no statistical test should be required to prove the difference.”
In most higher levels of evidence, there is a definite reliance on statistical formula and tests of significance, proving either difference or similarity. However, one should refrain from blindly trusting any result as “the absolute proof” if the statistical cutoff p value < 0.05 is reached.
There are a few infamous and controversial examples of how even a statistically significant yet realistically small difference has been blown out of proportion and brought in rather major changes in clinical practice. For example, use of tamoxifen and aromatase inhibitors in breast cancer was found to have similar survival rates. However, the disease-free survival period was slightly better with aromatase inhibitors. Though this is an unmissable statistical derivation, it means little to the patient. Notwithstanding this, multiple publications favored the replacement of tamoxifen by aromatase inhibitor, which is considered unjustified, in retrospect.
Publication Bias
“We do not know what we do not see.”
The process involved from the generation of data up to appearance in scientific literature leads to a host of possibilities of bias. Once analysis is done, if the result is “positive”, there is a tendency to hasten its submission. Upon submission, “positive” results have higher chance of acceptance by journals. On the contrary, “negative” results tend to be abandoned, and not worked upon further for publication. Even if it is eventually submitted to journals, a lot of time has elapsed. Even after submission, the chance of acceptance is diminished. All these constitute “publication bias”.
“In Situ” Publication Bias
“If I choose not to show, you do not get to see.”
Researchers are free to analyze the specific parameters that they wish to analyze, and hence this leads to writing up of only that data which the researcher feels relevant and important. The overall picture tends to be narrow-visioned, because a lot of what has to be presented lies shelved in the researcher's drawers.
Many initiatives have been taken to reduce such publication bias. This includes mandatory registration of clinical trial protocols with trial registries. This ensures that every protocol which is registered is analyzed and the details published within a given time frame.
The standard dictionary definition of “informatics” is “the sciences concerned with gathering and manipulating and storing and retrieving and classifying recorded information”. Hence, medical informatics can be regarded as “an interdisciplinary field combining systematic processing of data, information and knowledge in medicine and health care”.26
The definitions can vary and depend on the specific subfield they relate to. For example, clinical informatics will refer to the activities pertaining to clinical information; “pathology informatics” referring to pathological laboratory data, etc.8
Types of Data
Before we can make sense of what informatics systems can do with data, it is important to identify what types of data can be collected. Table 4 lists the various types of data, which we clinicians are otherwise familiar with.9 Figure 4 shows the differences between the traditional model and the “informatics” model of medical data handing.
TABLE 4   Types of clinical data.
Type of data
Brief description
  • Includes questionnaires or survey tools
  • It may be target-specific or population-specific
Admission data/Discharge data
Includes the demographic and treatment details of patients admitted in a healthcare facility
Administrative data/Claims data
Includes the details of patients who have submitted their records for the purpose of reimbursement or otherwise
Includes details of patients suffering from a particular condition, e.g., cancer registry
Population data
  • Includes (basic) information about the entire population
  • Birth and Death registration is one example
Electronic medical record
Includes the details of all complaints, evaluation, consultations, advice, interventions and improvement of individuals involved in one particular institution
zoom view
Fig. 4: Traditional and informatics model of healthcare information processing.
Advantages of Electronic Health Informatics
The health informatics evolution promises changes such as efficiency, EBM, enhancement of quality of care, etc. which are summarized in Figure 5.10
Artificial intelligence is simply defined as “the ability of machines to learn and display intelligence”. Such intelligence may be in stark contrast to the “natural” intelligence which is demonstrated by humans and animals.
The rise of artificial intelligence is supported by the rise of computer power, vast amounts of memory, ability to store data securely; this has led to the successful handling of increasingly complex learning tasks. Speech recognition, face recognition, advanced gaming, voice assistants, and self-driving vehicles are some examples.
The exponential rise in the volume of biomedical data generated has led to clinicians grappling with how to make sense of this vast data; the best way to deal with this is to automatism it using artificial intelligence systems.11
Computer Calculations versus Artificial Intelligence
The difference between simple use of mathematical calculators and artificial intelligence is vast.27
zoom view
Fig. 5: Possible improvements with health informatics.
Mathematical models enable computerized programs to identify patterns which are present in voluminous and complex data entities automatically. These are then used to make predictions and prognostications, important for clinicians. In traditional computer-based statistics, the main objective is to merely estimate the disease condition and score the severity or classify the disease conditions. However, machine learning has the ability to build on automated clinical decisions for the optimal management of conditions. This assists doctors to solve clinical problems. The accuracy of the model improves when more data is inputted. Supervised learning, unsupervised learning, self-learning, artificial neural networks, decision trees, and support vector machines are some examples of machine learning modes.
Simulation technology development is an important offshoot of medical informatics. The Medical Council of India (MCI) is also promoting and emphasizing the use of simulation technology for teaching undergraduates and postgraduates. The steady advances in patient activism and unfavorable teacher:patient:student ratios make simulation-based teaching imperative. Readers are encouraged to get accustomed to this exciting field of medical education. The flipside of utilization of applications such as YouTube, where vast amount of material may be available, is that there may be loss of authenticity and accuracy.
Though not exhaustive, a list of the components of an electronic health record (EHR) is mentioned in Figure 6. The ideal EHR allows for flexibility and inclusion of information pertaining to specific problems such as maternal conditions, neonatal outcomes, etc. Since pregnancy has both a discrete starting and ending point, obstetrics is one field where accuracy of EHR can be easily achieved.12
Ensuring Uniformity and Interuser Portability of Health Information and the Indian Perspective
One of the major disadvantages of the traditional method of health information process is the arbitrary manner in which data is collected. However, the informatics approach can also be plagued by arbitrariness if uniformity is not maintained.
zoom view
Fig. 6: Components of an electronic health record.
TABLE 5   Data sets and suggested standards.
Data gathered
Suggested standard
Structured clinical information exchange
Fast Healthcare Interoperability Resources® (FHIR 4)
Clinical terminology
Coding system for diseases
Laboratory measurements, test-panels, etc.
Still images
Radiological investigations
Successfully classifying “cause of death” was one of the initial successes of medical informatics. The use of the International Classification of Diseases (ICD), with its regular modifications, greatly helped in ensuring uniformity.
Now, each and every data set of health care informatics should undergo standardization (Table 5), as promulgated by the Ministry of Health and Family Welfare's (MoHFW) National Digital Health Blueprint 2017. This blueprint envisages “creation of a national digital health ecosystem that supports universal health coverage in an efficient, accessible, inclusive, affordable, timely, and safe manner, through provision of a wide-range of data, information and infrastructure services, duly leveraging open, interoperable, standards-based digital systems, and ensuring the security, confidentiality and privacy of health-related personal information”.13
Cardiotocography/Electronic Fetal Monitoring
Conventional electronic fetal monitoring uses paper tracings and human visual interpretation.28
Can the dependence on paper be reduced? Can this be done on a handheld mobile device? Yes. Das et al.14 have proved in a Indian setting that there is good clinical accuracy and inter-rater agreement between interpretation of antepartum/intrapartum traces visualized conventionally and those on a mobile cardiotocography (CTG) device. The interobserver variability has been overcome by Sbrollini et al.,15 who have developed and validated automatic identification, interpretation, and classification of fetal heart rate (FHR) abnormalities using computerized algorithms. This is a rapidly evolving field.
Estimation of Fetal Aneuploidy Risk
A few decades ago, the only risk estimation of fetal aneuploidy was based on age. One of the major areas of success of health informatics is in the prediction of fetal aneuploidy risk. Using demographic, physical (examination), ultrasonographic, and biochemical parameters, multiple statistical analytics are done to determine risk ratios. However, it should be noted that machine learning approaches are likely to be even better than the conventional informatics approach.16
Cervical Cancer Screening
Cervical cancer screening has moved on from conventional smears to liquid-based cytology (LBC). Lack of skilled manpower has been cited as a major reason for inadequate coverage of screening. Feasibility of screening of patients at remote locations using smartphones by nurses has been demonstrated by Sharma et al.17 One skilled cytologist using a centralized computer can analyze thousands of images generated at different locations, enabling better coverage. Machine learning approaches are being studied and have been proven to be more accurate in Indian settings.18
Male Infertility
For over half a century, diagnosis has relied upon manual visual counting of spermatozoa of semen smeared over a slide. Computer-assisted analysis has helped recreate the volumetric three-dimensional spaces similar to the intrauterine milieu. This method has much higher accuracy than conventional analysis.19 Here again, machine learning models are in the nascent stage and further expansion is expected in the subject.20
Carcinoma Ovary
The development of a vast database of the molecular and genomic variations in serous ovarian cancer is a major contribution of medical informatics to our field. “Individuals with similarities in genetic makeup tend to respond better with some specific chemotherapeutic agents than the others”—is the simple principle applied. This is an example for “personalized medicine” or “precision medicine”.21 This individualization of treatment based on patient characteristics not only helps in improving accuracy, prevention of side effects but also in reduction of economic burden.
The application of “big data” in this context is exemplified by the establishment of data portals such as the “Clinical Proteomic Tumor Analysis Consortium (CPTAC)” portal. This is an online repository of all available clinical data including proteomic characterization, as a part of the Cancer Genome Atlas. Such open-source models give rise to hitherto unavailable opportunities for improvement of patient care.22 A completely online Indian National Cancer Registry Programme is also functional.23
National Registries
A contemporary example of the use of informatics in developing good data is the barrage of minute-by-minute facts and figures available online about the coronavirus disease 2019 (COVID-19) pandemic. To this end, FOGSI's National Registry on COVID-19 Infection in Pregnancy is an excellent tool which could be developed rapidly only due to informatics.24
Telemedicine can be defined as the “healthcare service delivery, distance being a critical factor, provided by healthcare professionals by utilizing information and communication technologies for the exchange of reliable information for diagnosis, management, and prevention of disease”. Telemedicine is the result of enhanced penetration of informatics into both the medical field and ease of availability by the population. The obvious advantages are quicker access to services, better healthcare delivery in remote areas, and feasible option during accidents, epidemics, and disasters. While in some situations like chronic diseases, long-term dependence on telemedicine is possible by interlinking patients, physicians, laboratories, and pharmacies; in some situations, like hypoglycemic episodes, short-term usage is appropriate. Telemedicine can be administered using short messaging services (SMS), voice messages over the phone, livestreaming over internet or suitable application platforms, or via email.
The National Medical Commission (erstwhile MCI) have published the “Telemedicine Practice Guidelines: Enabling Registered Medical Practitioners to Provide Healthcare Using Telemedicine” in March 2020.25
In this elaborate document, detailed definitions of the terms “telemedicine” and “telehealth” are provided. It is summarized that most consultations are in the form of:
  • Providing health education as appropriate in the case; and/or
  • Providing counseling related to specific clinical condition; and/or
  • Prescription of medicines
The various tools for telemedicine are enumerated and a classification is provided:
  • Based on the mode of communication (video/audio/text based)29
  • Timing of transmission of information [real-time (immediate)/asynchronous (late)]
  • The purpose of the consultation (emergency/nonemergency)
  • Interaction between the individuals [patient to Registered Medical Practitioner (RMP)/RMP to RMP/caregiver to RMP, etc.)].
Some salient principles that are to be kept in mind when using telemedicine are listed:
  • Accurate identification of the patient using digital information like phone number/email ID is needed.
  • Accurate verification of the doctors’ details such as qualifications and registration number is needed.
  • Ascertaining that the patient is willing to abide for advice suggesting an in-person referral if the doctor deems fit, and in situations such as life-threatening emergencies, in-person consultation is needed.
  • An appropriate form of consent (implied if patient initiates the consultation) has to be ensured.
  • Adherence to the explicit details regarding medicine prescription should be ensured.
  • Adherence to the tenets regarding medical ethics, data privacy (with respect to images and videos) and confidentiality should hold importance.
The strengths and limitations based on technical, financial, and feasibility issues are explained in the guideline. The commission has also proposed a compulsory training in telemedicine for all RMPs. Immaterial of which technological platform is used for communicating with the patient, the basic tenets of medical ethics which govern in-patient consultations, should be adhered to at all times. All RMPs are encouraged to familiarize themselves with this important document.25
Understanding the levels of EBM and learning how to utilize the available information is an essential skill set which should be learned by every practicing clinician. As the world uses digital platforms for more and more aspects of daily life, advances in information technology should also be assimilated and incorporated by every practitioner.
The singular aim of clinicians is to offer the best care to their patients. Evidence-based medicine (EBM) is a systematic collation and rational presentation of clinical information gathered in settings all over the world. Simply put, it aims at answering questions like “In this patient, what works; what does not work?” EBM is “a lens” through which all medical information should be viewed. The use of modern advances in information technology in the improvement of patient care is “medical informatics”. The modern doctor should acquaint himself and embrace the exciting changes in this field.
  1. Tenny S, Varacallo M. Evidence Based Medicine. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing;  2021.
  1. Masic I, Miokovic M, Muhamedagic B. Evidence-based medicine—new approaches and challenges. Acta Inform Med. 2008;16(4):219–25.
  1. Thoma A, Eaves FF 3rd. A brief history of evidence-based medicine (EBM) and the contributions of Dr David Sackett. Aesthet Surg J. 2015;35(8):NP261–3.
  1. Royal College of Obstetricians and Gynaecologists. Green-top guideline development. [online] Available from: [Last accessed September, 2021].
  1. Ford LG. Melnyk BM. The underappreciated and misunderstood PICOT question: a critical step in the EBP process. Worldviews Evid Based Nurs. 2019;16(6):422–3.
  1. Jassem J. Bright and dark sides of evidence-based Medicine. Pol Arch Med Wewn. 2016;126(5):347–52.
  1. Braithwaite RS. Evidence-based medicine: clinicians are taught to say it but not taught to think it. BMJ Evid Based Med. 2019;24(5):165–7.
  1. Medical informatics. [online] Available from: [Last accessed September, 2021].
  1. Goodin A, Delcher C, Valenzuela C, Wang X, Zhu Y, Roussos-Ross D, et al. The power and pitfalls of big data research in obstetrics and gynecology: a consumer's guide. Obstet Gynecol Surv. 2017;72(11):669–82.
  1. Emerging into E-health information management. [online] Available from: [Last accessed September, 2021].
  1. Wang R, Pan W, Jin L, Li Y, Geng Y, Gao C, et al. Artificial intelligence in reproductive medicine. Reproduction. 2019;158:R139–54.
  1. Ministry of Electronics and Information Technology, Government of India. National digital health blueprint. [online] Available from: [Last accessed September, 2021].
  1. Ministry of Health and Family Welfare, Government of India. Electronic health record standards - 2016 for India. [online] Available from: [Last accessed September, 2021].
  1. Das MK, Tripathi R, Kashyap NK, Fotedar S, Bisht SS, Rathore AM, et al. Clinical validation of mobile cardiotocograph device for intrapartum and antepartum monitoring compared to standard cardiotocograph: an Inter-Rater Agreement Study. J Family Reprod Health. 2019;13(2):109–15.
  1. Sbrollini A, Carnicelli A, Massacci A, Tomaiuolo L, Zara T, Marcantoni I, et al. Automatic identification and classification of fetal heart rate decelerations from cardiotocographic recordings. Annu Int Conf IEEE Eng Med Biol Soc. 2018;2018:474–7.
  1. Yang J, Ding X, Zhu W. Improving the calling of non-invasive prenatal testing on 13-/18-/21-trisomy by support vector machine discrimination. PLoS One. 2018;13(12):e0207840.
  1. Sharma D, Rohilla L, Bagga R, Srinivasan R, Jindal HA, Sharma N, et al. Feasibility of implementing cervical cancer screening program using smartphone imaging as a training aid for nurses in rural India. Public Health Nurs. 2018;35(6):526–33.

  1. 30 Kudva V, Prasad K, Guruvare S. Automation of detection of cervical cancer using convolutional neural networks. Crit Rev Biomed Eng. 2018;46(2):135–45.
  1. Talarczyk-Desole J, Berger A, Taszarek-Hauke G, Hauke J, Pawelczyk L, Jedrzejczak P. Manual vs. computer-assisted sperm analysis: can CASA replace manual assessment of human semen in clinical practice? Ginekol Pol. 2017;88(2):56–60.
  1. Goodson SG, White S, Stevans AM, Bhat S, Kao CY, Jaworski S, et al. CASAnova: a multiclass support vector machine model for the classification of human sperm motility patterns. Biol Reprod. 2017;97(5):698–708.
  1. Cojocaru E, Parkinson CA, Brenton JD. Personalising treatment for high-grade serous ovarian carcinoma. Clin Oncol (R Coll Radiol). 2018;30(8):515–24.
  1. Edwards NJ, Oberti M, Thangudu RR, Cai S, McGarvey PB, Jacob S, et al. The CPTAC data portal: a resource for cancer proteomics research. J Proteome Res. 2015;14(6):2707–13.
  1. National Cancer Registry Programme (Indian Council of Medical Research). Development of an Atlas of Cancer in India. [online] Available from: [Last accessed September, 2021].
  1. FOGSI's National Registry on COVID-19 Infection in Pregnancy. [online] Available from: [Last accessed September, 2021].
  1. Ministry of Health and Family Welfare, Government of India. Telemedicine Practice Guidelines: Enabling Registered Medical Practitioners to Provide Healthcare Using Telemedicine. [online] Available from: [Last accessed September, 2021].
1. What is evidence based medicine? What is meant by Levels of Evidence? Discuss the advantages, disadvantages and problems in applications of evidence based medicine in daily clinical practice.
2. What is a Randomized Controlled Trial? What are the features of a well-conducted Randomized Controlled Trial? Explain using practical clinical examples.
1. Discuss the role of information technology in medicine, with specific reference to obstetrics and gynaecology.
2. Evidence pyramid.
3. Publication bias.
1. The following are components of the Evidence Based Medicine Triad, except:
  1. Good Clinical Expertise
  2. Patient preferences and values
  3. Availability of medico-legal consultant
  4. Best available evidence from research
2. All statements about EBM are true, except:
  1. Introduced by Prof David Sackett in Canada
  2. Focusses on “trusting the experts”
  3. Focusses on “trusting the numbers”
  4. Is a gradual movement rather than a revolutionary change
3. Which of the following is true?
  1. Case series provide a good guide to clinical management of common conditions
  2. Case control studies are appropriate for rare diseases
  3. Retrospective study designs are equivalent to prospective study designs
  4. Expert opinions are usually consistent and homogenous
4. Which of the following is false?
  1. Randomized controlled trials form the “gold standard” in Evidence Based Medicine
  2. All topics in medicine can be resolved by Randomized Controlled Trials
  3. Systematic review of RCTs form the highest level of evidence available
  4. It is possible to classify different RCTs as having high probability of bias or lesser probability of bias
5. While obtaining the best evidence all these steps should be followed, except:
  1. Narrow down the clinical dilemmas into precise questions
  2. Fit the question into a PICOT format
  3. Search for evidence from the single best source
  4. Check for applicability of evidence obtained in the local setting
6. A clinician wants to check the usefulness of a new antihypertensive drug for management of preeclampsia. Regarding generation of good quality evidence, which one of the following statements is appropriate?
  1. Interviewing of many experts and noting their views and opinions about how the drug has performed in their patients is likely to yield good quality evidence
  2. Analysis of the clinical records of patients who have used the drug in the past one year is likely to yield the best evidence
  3. It would be acceptable to start the new antihypertensive drug for all forthcoming patients to generate good quality evidence
  4. Allocating few patients to the new drug and other patients to the existing gold standard drug is likely to generate good quality evidence
7. Artificial Intelligence/Machine Learning. Find the false statement:
  1. They can analyze patterns, predict and prognosticate clinical conditions
  2. There is standardization in data entry and data output.
  3. Data access is possible at locations by multiple individuals
  4. Providing more data reduces the accuracy of the machine learning process
8. All are true about Telemedicine, except:
  1. It ensures accessibility to remote areas also
  2. It should be preferred during epidemic31
  3. The usual tenets of ethical practice in medicine are applicable
  4. It should not be used for chronic diseases.
9. While reading and evaluating a published scientific medical article, which is appropriate:
  1. All published material should be given equal merit and accepted unconditionally
  2. It is acceptable to skip reading the analysis and look into only the conclusions
  3. Evidence generated on patients of different population groups should be extrapolated to local population with utmost caution
  4. A statistical significance of p<0.05 is considered absolute mathematical proof
10. With respect to the PICO methodology of forming a research question, choose the correct combination:
  1. P-Population, I-Information, C-Comparison, O-Outcome
  2. P-Population, I-Intervention, C-Comparison, O-Outcome
  3. P-Population, I-Information, C-Complication, O-Outcome
  4. P-Population, I-Intervention, C-Complication, O-Outcome
1. c
2. b
3. b
4. b
5. c
6. d
7. d
8. d
9. c
10. b
Ramalingappa C Antaratani, Sanjana K
Today, clinical research is a necessity to establish the safety and efficacy of medical products and practices. All that we have known about the medical products or treatments have come from randomized control clinical trials. A general definition of human research is—“Any proposal related to human subjects including healthy volunteers that cannot be considered as a part of accepted clinical management or public health practice and the one that involves either physical or psychological intervention or observation; or collection, storage or dissemination of information related to individuals”.1 Before medical products are introduced to the market or to public health programs, they must undergo a series of investigations designed to evaluate the safety and efficacy and detailed information on the method of administration, dosage, contraindications, warnings, precautions, interactions, and safely information has to be documented.
The research work can be relied upon only if they have been conducted as per the principles and standards collectively known as “Good clinical research practice” (GCP). The responsibility of GCP is to be shared by the sponsors, investigators, site staff, contract research organizations (CROs), ethical committees, regulatory authorities, and the research subjects.
Good clinical practice is an international ethical and scientific quality standard for designing, conduct, performance, monitoring, recording, auditing, analysis, and reporting of clinical trials. GCP assures that data and reported results are credible, accurate and that the rights, integrity, and confidentiality of trial subjects are respected and protected.2
It is interesting to know why and how the GCP were put forward. Like it is said “curiosity is the mother of discoveries”, many curious and enthusiastic researchers since a very long time carried out experiments on humans and animals. On a negative note, this led to disastrous effects on mankind including death due to unregulated and unlawful research activities. This made laws for carrying out research very much necessary. The events that led to the acts and the acts perse have been chronologically tabulated in Table 1.
The International Council for Harmonisation-Good Clinical Practice (ICH-GCP) is defined as a harmonized standard that protects the rights, safety, and welfare of human subjects, minimizes the exposure of human beings to investigational products, improves the quality of data, speeds up marketing of new drugs and decreases the cost to sponsors as well as to the public.
  • Increase in ethical awareness among the people
  • Improved methods of clinical trials
  • Better understanding of concept of clinical trial
  • Public or political concern over the aspects of safety
  • Frauds and accidents during the clinical trials
  • Increasing research and development costs
  • Increasing competition
  • Mutual recognition of data
  • New market structure.32
TABLE 1   History of good clinical practice (GCP) recommendations.
S. No
Landmark act/declaration
Events that forced the act
Laws laid down by the act
460 bc
The Hippocratic oath
Brought out the concept of “Good physician”
Food and drugs act
Over the counter sale of harmful and lethal drugs in the United States
US Food, Drugs, And Cosmetic Act
Compulsory testing of drugs for safety before marketing
Nuremberg code3
Unethical and horrific experiments conducted during World War II at Nazi war camps
Need for scientific basis in research on human subjects and voluntary consent
Declaration of Human Rights
Atrocities of World War II
Further reiterated the human factor involved in medical experiments
Kefauver–Harris amendment
Severe fetal limb deformities linked to the use of maternal thalidomide
Required the Food and Drug Administration (FDA) to evaluate all new drugs for safety and efficacy
Declaration of Helsinki by the World Medical Association4
Statement of ethical principles to provide guidance to physicians and participants in Human Research Forms
The Belmont report5
For the protection of human subjects of biomedical research
Laid down principles of respect for people, beneficence, and justice
International guidelines for biomedical research involving human subjects by the World Health Organization (WHO) and the Council for International Organizations of Medical Sciences (CIOMS)
Issued a document entitled “International guidelines for biomedical research involving human subjects”
ICH-GCP guidelines6
International GCP inconsistencies
Standards to protect the rights, safety, and welfare of human subjects
  • Clinical trials should be conducted in accordance with ethical principles that have their origin from the declaration of Helsinki, and are consistent with GCP.
  • Before a trial is initiated, probable risks and inconveniences should be weighed against anticipated benefit for the individual trial subject and society. A trial should be initiated and continued only if the anticipated benefits outweigh the risks.
  • The rights, safety, and well-being of the trial subjects are the most important considerations and should be considered over the interest of science and society.
  • The available nonclinical as well as clinical information on a particular investigational product should be adequate to support the proposed clinical trial.
  • Clinical trials must be scientifically sound, and need to be described in a clear and detailed protocol.
  • A trial should be conducted according to the protocol that has received prior institutional review board (IRB)/independent ethics committee (IEC) approval/favorable opinion.
  • The medical care that is given the subjects and medical decisions made on behalf of subjects should always be the responsibility of a qualified physician.
  • Each individual involved in conducting a particular trial should be qualified by education, training, and experience to perform his or her respective tasks.
  • Freely given informed consent from every subject is a must prior to participation in clinical trials.
  • The clinical trial information should be recorded, handled, and stored in a way that helps its accurate reporting, interpretation, and verification.
  • The confidentiality of records which identify the subjects should be protected hence respecting the privacy and confidentiality of the subjects.
  • Investigational products must be manufactured, handled, and stored in accordance with good manufacturing practice (GMP). They must be used in accordance with the approved protocol.
  • Systems with procedures that can assure the quality of the trial should be implemented.
Ethical Principles of GCP
The ICH-GCP guidelines are considered the “Bible” of clinical trials and have become a global law which safeguards humanity, it has three basic ethical principles being:
  1. Respect for persons
  2. Beneficence
  3. Justice.33
The process of clinical research is guided by a sequence of activities for which the sponsors, investigators, ethics committees, and regulatory authorities are collectively responsible. Table 2 briefly describes the key activities involved in the conduct of a clinical trial and the individuals responsible for each of them.
Research in pregnant women is associated with scientific, legal, and ethical problems. The physiology of pregnancy changes drastically over weeks, months, and trimesters within and between the maternal body, placenta, and fetus. Attitudes of researchers toward inclusion of women in trials have changed grossly over the past few decades although a gap still exists in the available data on health and disease in pregnant women.
TABLE 2   Key activities in conducting a clinical trial.
S. No.
Key trial activity
Details of the activity
Development of trial protocol
Sponsor in consultation with clinical investigators
Risk identification, study design, statistical methodology
Development of standard operating procedures (SOPs)
Sponsors, clinical investigators, ethics committees, institutional review boards, contract research organizations (CROs)
Develop SOPs that define responsibilities, records, and methods to be used for study-related activities
Development of support systems and tools
Tools to facilitate the conduct of the study and collection of data required by the protocol
Generation and approval of trial-related documents
Provision of standardized forms and checklists to assist the clinical investigator to capture and report data
Selection properly qualified, trained, and experienced investigators and study personnel
Sponsors should review the requirements of the study protocol and recruit appropriate staff who are qualified
Ethics committees review and approval of the protocol
Study to be reviewed by ethics committee or institutional review board
Review by regulatory authorities
To ensure that the study is appropriately designed to meet its stated objectives