Obstetrics Image Library

Chapter 1

Figure 1.1 Gestation calendar wheel.
Figure 1.2 Gestation calendar App on a smartphone. (Courtesy of Dr Andrew Yu, Yale University.)
Figure 1.3 A customized symphysis–fundal height chart illustrating the 10th, 50th and 90th centiles and normal fetal growth. (Courtesy of Perinatal Institute.)
Figure 1.4 Palpation of the gravid abdomen.
Figure 1.5 Palpation of the fetal head to assess engagement.
Figure 1.6 A Cusco speculum.

Chapter 3

Figure 3.1 Population centile chart for estimated fetal weight by ultrasound measurements. Fetus (A) has normal growth; fetus (B) has suboptimal growth.
Figure 3.2 Diagrammatic representation of fetal circulation. (Adapted from Harrington K, Campbell S. A Colour Atlas of Doppler Ultrasonography in Obstetrics, London: Arnold, 1995.)
Figure 3.3 Midgut herniation.
Figure 3.4 Tracheo-oesophageal fistula.
Figure 3.5 Posterior urethral valves. (A) The typical ‘keyhole’ sign in the fetal bladder (B), where the dilated upper posterior urethra is indicated (white arrow); (B) dilatation of the collecting system of the fetal kidney (K).
Figure 3.6 Amniotic fluid measurement and normal ranges.
Figure 3.7 Ultrasound image showing the ‘double bubble’ appearance and polyhydramnios associated with duodenal atresia.

Chapter 4

Figure 4.1 Ultrasound probe: abdominal.
Figure 4.2 Ultrasound probe: transvaginal.
Figure 4.3 Ultrasound sac showing yolk sac (YS) and embryo (E) with the vitelline duct (VD).
Figure 4.4 Ultrasound image showing empty gestation sac (arrowheads) in a case of blighted ovum.
Figure 4.5 Biparietal diameter (BPD). 1, anterior ventricle; 2, posterior ventricle; 3, cerebral hemisphere. OFD, occipitofrontal diameter.
Figure 4.6 Femur length.
Figure 4.7 Abdominal circumference measurement demonstrating the correct section showing the stomach (S) and the umbilical vein (U).
Figure 4.8 Ultrasound plots on reference range for head circumference (HC), abdominal circumference (AC) and estimated fetal weight in a case of early-onset fetal growth restriction (FGR). Note that HC remains above 5th centile while the AC falls below 5th centile. This is a case of asymmetric FGR with head sparing.
Figure 4.9 Early twin dichorionic pregnancy (arrows); note the ‘peaked’ inter-twin membrane.
Figure 4.10 A fetal cardiotocograph showing a baseline of 150 bpm but with reduced variability (rv).
Figure 4.11 An admission cardiotocograph from a term pregnancy. Although the baseline fetal heart rate is normal, there is reduced variability, an absence of fetal heart rate accelerations and multiple decelerations (d). The decelerations were occurring after uterine tightening and are therefore termed ‘late’.
Figure 4.12 A normal fetal cardiotocograph showing a normal rate, normal variability (v) and the presence of several accelerations (a).
Figure 4.13 Biophysical profile scoring system.
Figure 4.14 Normal umbilical arterial Doppler waveform.
Figure 4.15 Reverse end-diastolic flow in the umbilical artery.
Figure 4.16 Reduced end-diastolic flow in umbilical artery compared to normal in 4.14.
Figure 4.17 Middle cerebral artery Doppler showing increased diastolic flow with possible redistribution to brain in hypoxia.
Figure 4.18 Normal ductus venosus Doppler waveform.
Figure 4.19 Reverse flow in ductus venosus.
Figure 4.20 (A) Uterine artery waveform with diastolic notch, and (B) pulsatility index (PI) above 97th centile.
Figure 4.21 Plot of fetal head circumference and fetal abdominal circumference.

Chapter 5

Figure 5.1 A, B: Chorionic villus sampling. (Adapted from the RCOG information leaflet of both approaches.)
Figure 5.2 Amniocentesis. (Adapted from the RCOG information leaflet.)
Figure 5.3 Ultrasound image demonstrating the measurement of nuchal translucency (arrow).
Figure 5.4 Normal cranial anatomy in the transcerebellar plane. Note the ovoid head shape and the dumb bell-shaped cerebellum. BPD, biparietal diameter; CB, cerebellum; OFD occipitofrontal diameter.
Figure 5.5 is in a similar plane in Ms N, whose fetus has a neural tube defect. Note the scalloped head shape anteriorly (lemon shaped) marked by the white arrows and the banana-shaped cerebellum (red arrow). A, anterior; P, posterior.
Figure 5.6 Ultrasound image of gastroschisis (arrow). AF, amniotic fluid; S, fetal stomach; Sp, fetal spine.
Figure 5.7 Ultrasound image of exomphalos, showing the sac containing the herniated bowel (white arrow). AF, amniotic fluid; S, fetal stomach; Sp, fetal spine.

Chapter 6

Figure 6.1 Fibroids complicating pregnancy. The tumour in the anterior wall of the uterus (A) has been drawn up and out of the pelvis as the lower segment formed, but the fibroid (B) arising from the cervix remains in the pelvis and will obstruct labour.
Figure 6.2 Obstetric thromboprophylaxis risk assessment and management. (Adapted from RCOG Green-top Guideline No. 37a, April 2015.)
Figure 6.3 (A) Frank breech (also known as extended breech) presentation with extension of the legs; (B) breech presentation with flexion of the legs; (C) footling breech presentation; (D) transverse lie; (E) oblique lie.
Figure 6.4 External cephalic version. (A) The breech is disengaged from the pelvic inlet; (B) version is usually performed in the direction that increases flexion of the fetus and makes it do a forward somersault; (C) on completion of version, the head is often not engaged for a time; (D) the fetal heart rate should be checked after the external version has been completed.
Figure 6.5 Loveset’s manoeuvre.
Figure 6.6 Mauriceau–Smellie–Veit manoeuvre for delivery of the head.
Figure 6.7 Delivery of the aftercoming head with forceps.
Figure 6.8 The parental genotype determinants of rhesus phenotype.
Figure 6.9 The mechanism of rhesus sensitization (A) and fetal red cell destruction (B).
Figure 6.10 Middle cerebral artery Doppler waveform analysis (A) of a fetus with anaemia secondary to Rhesus disease demonstrating an increased peak systolic velocity, and the same fetus (B) 48 hours following an intrauterine transfusion.

Chapter 7

Figure 7.1 Incidence of monozygotic and dizygotic twin pregnancies. DCDA, dichorionic diamniotic; MCDA, monochorionic diamniotic.
Figure 7.2 Ultrasound appearance of dichorionic (A) and monochorionic (B) twin pregnancies at 12 weeks’ gestation. Note that there appears to be a single placental mass but in the dichorionic type there is an extension of placental tissue into the base of the inter-twin membrane, forming the lambda sign.
Figure 7.2 Ultrasound appearance of dichorionic (A) and monochorionic (B) twin pregnancies at 12 weeks’ gestation. Note that there appears to be a single placental mass but in the dichorionic type there is an extension of placental tissue into the base of the inter-twin membrane, forming the lambda sign.
Figure 7.3 Gestational age distribution at delivery of singleton, twin and triplet pregnancies.
Figure 7.4 Internal podalic version.

Chapter 8

Figure 8.1 Evolution of the human skull.
Figure 8.2 Global incidence of preterm birth. (Source: Born Too Soon Executive Summary Group; Kenney MV, Howson CP, McDougall L, Lawn JE (2012). Executive summary for Born Too Soon: The Global Action Report on Pre-term Birth. March of Dimes, PMNCH, Save the Children, World Health Organization.)
Figure 8.3 Rates of preterm birth as a percentage of all births 1990–2013. (Source: Centers for Disease Control and Prevention.)
Figure 8.4 Survival chances of preterm infants by gestational age at birth. (Source: Rysavy MA, Li L, Bell EF, et al. [2015]. Between-hospital variation in treatment and outcomes in extremely preterm infants. N Engl J Med 372(19):1801–11.)
Figure 8.5 Morbidity according to gestational age at birth. Gestational age was significantly correlated with morbidity risk. (Source: Shapiro-Mendoza CK, Tomashek KM, Kotelchuk M, et al. [2008]. Effect of late-preterm birth and maternal medical conditions on newborn morbidity risk. Pediatrics 121:e223–32.)
Figure 8.6 Causes of preterm birth.
Figure 8.7 (A) Magnetic resonance imaging (MRI) in a preterm infant with a gestational age at birth of 32 weeks. Routine ultrasound performed at 2 weeks of age shows cystic changes in the distribution of the right middle cerebral artery. MRI, inversion recovery, axial slice, performed at 40 weeks postmenstrual age, shows an area of cavitation and ex-vacuo dilatation of the right ventricle. Also note the absence of myelination of the posterior limb of the right internal capsule. The infant developed a moderate hemiplegia and has a Developmental Quotient of 91 at 24 months of age. (B, C) Cystic and non-cystic periventricular leukomalacia (PVL) and germinal matrix haemorrhage–intraventricular haemorrhage (GMH-IVH) and GMH-IVH with periventricular haemorrhagic infarction (PHI). Coronal sections from the brain of a 28-week-old premature infant. GE: ganglionic eminence; GP: globus pallidus; P: putamen; SVZ: subventricular zone; T: thalamus.(From Volpe JJ [2009]. Brain injury in premature infants: a complex amalgam of destructive and developmental disturbances. Lancet Neurol 8:110–24.)
Figure 8.7 (A) Magnetic resonance imaging (MRI) in a preterm infant with a gestational age at birth of 32 weeks. Routine ultrasound performed at 2 weeks of age shows cystic changes in the distribution of the right middle cerebral artery. MRI, inversion recovery, axial slice, performed at 40 weeks postmenstrual age, shows an area of cavitation and ex-vacuo dilatation of the right ventricle. Also note the absence of myelination of the posterior limb of the right internal capsule. The infant developed a moderate hemiplegia and has a Developmental Quotient of 91 at 24 months of age. (B, C) Cystic and non-cystic periventricular leukomalacia (PVL) and germinal matrix haemorrhage–intraventricular haemorrhage (GMH-IVH) and GMH-IVH with periventricular haemorrhagic infarction (PHI). Coronal sections from the brain of a 28-week-old premature infant. GE: ganglionic eminence; GP: globus pallidus; P: putamen; SVZ: subventricular zone; T: thalamus.(From Volpe JJ [2009]. Brain injury in premature infants: a complex amalgam of destructive and developmental disturbances. Lancet Neurol 8:110–24.)
Figure 8.8 An example of white matter injury due to periventricular leukomalacia. Two cell types are shown staining positive for TNF-alpha, the larger more densely stained cells with prominent cytoplasmic processes (astrocytes, arrows) and smaller, less densely stained cells with fewer cytoplasmic processes (microglial cells, arrowheads).
Figure 8.9 Schematic diagram of different types of congenital uterine anomalies. Uterine müllerian anomalies are associated with an increased risk of preterm delivery.
Figure 8.10 Cervical length and the risk of preterm (<34 weeks) delivery.
Figure 8.11 (A) Normal cervix; (B) cervical length and funnelling on ultrasound.
Figure 8.11 (A) Normal cervix; (B) cervical length and funnelling on ultrasound.
Figure 8.12 Cervical cerclage seen on ultrasound (arrows).

Chapter 9

Figure 9.1 Physiological change of spiral arteries by invading trophoblasts.
Figure 9.2 The proposed aetiology of pre-eclampsia.

Chapter 11

Figure 11.1 Primary syphilitic chancre. (Courtesy of Dr Raymond Maw, Royal Victoria Hospital, Belfast.)
Figure 11.2 Ultrasound of a fetal brain demonstrating intracranial calcification secondary to CMV infection. (Courtesy of Dr Ed Johnstone, St Mary's Hospital, Manchester.)
Figure 11.3 Primary genital herpes. (Courtesy of Dr Richard Lau, St George’s Hospital, London.)
Figure 11.4 Fetal ascites. (Courtesy of Dr Ed Johnstone, St Mary's Hospital, Manchester.)
Figure 11.5 Middle cerebral Doppler to test for fetal anaemia. (Courtesy of Dr Ed Johnstone, St Mary's Hospital, Manchester.)

Chapter 12

Figure 12.1 The bony pelvis.
Figure 12.2 The pelvic brim.
Figure 12.3 Sagittal section of the pelvis demonstrating the anterior–posterior (A–P) diameters of the inlet and outlet.
Figure 12.4 The pelvic outlet.
Figure 12.5 The gynaecoid pelvis: (A) brim; (B) lateral view; (C) outlet.
Figure 12.6 The android pelvis: (A) brim; (B) lateral view; (C) outlet.
Figure 12.7 The anthropoid pelvis: (A) brim; (B) lateral view; (C) outlet.
Figure 12.8 The platypelloid pelvis: (A) brim; (B) lateral view; (C) outlet.
Figure 12.9 The musculofascial gutter of the levator sling.
Figure 12.10 The perineum, perineal body and pelvic floor from below, showing superficial (A) and deeper (B) views. The pelvic floor muscles are made up of the levator ani (pubo-coccygeus and ilio-coccygeus).
Figure 12.11 The fetal skull from the superior and lateral views.
Figure 12.12 Schematic representation of moulding of the fetal skull.
Figure 12.13 The diameters of the fetal skull.
Figure 12.14 The effect of fetal attitude on the presenting diameter.
Figure 12.15 The thick upper segment and the thin lower segment of the uterus at the end of the first stage of labour. The dotted lines indicate the position assumed by the uterus during contraction.
Figure 12.16 Descent and flexion of the head followed by internal rotation and ending of the head by extension.
Figure 12.17 External rotation of the head after delivery as the anterior shoulder rotates forward to pass under the suprapubic arch.
Figure 12.18 A normal cardiotocograph (CTG), showing a baseline fetal heart rate of approximately 120 bpm, frequent accelerations, baseline variability of 10–15 bpm and no decelerations. The uterus is contracting approximately once every 5 minutes.
Figure 12.19 A typical partogram. This is a partogram of a nulliparous woman of short stature with a big baby and an ­augmented labour. The labour culminates with an emergency caesarean section for cephalopelvic disproportion.
Figure 12.20 Signs of separation and descent of the placenta. After separation, the uterine upper segment rises up and feels more rounded.
Figure 12.21 Delivering the placenta by controlled cord traction.
Figure 12.22 Abnormalities of the partogram
Figure 12.23 A pathological cardiotocograph (CTG) secondary to uterine hyperstimulation.
Figure 12.24 Vaginal palpation of the head in the right occipito-posterior position. The circle represents the pelvic cavity, with a diameter of 12 cm. The head is poorly flexed so that the anterior fontanelle is easily felt.
Figure 12.25 Vaginal examination in the left mento-­anterior position. The circle represents the pelvic cavity, with a diameter of 12 cm.
Figure 12.26 The mechanism of labour with a face presentation. The head descends with increasing extension. The chin reaches the pelvic floor and undergoes forward rotation. The head is born by flexion.
Figure 12.27 Brow presentation. The head is above the pelvic brim and not engaged. The mento-vertical diameter of the head is trying to engage in the transverse diameter at the brim.
Figure 12.28 Vaginal examination with brow presentation. The circle represents the pelvic cavity, with a diameter of 12 cm. The mento-vertical diameter of 13 cm is too large to permit engagement of the head.
Figure 12.29 Deep transverse arrest of the head.
Figure 12.30 Sagittal section of the lumbosacral spinal cord.
Figure 12.31 Needle positioning for an epidural anaesthetic. Midline (A) and paramedian (B) approaches.
Figure 12.32 Fetal bradycardia to a heart rate of 90 bpm, lasting approximately 11 minutes.
Figure 12.33 The four most common patterns of fetal presentation in a twin pregnancy.

Chapter 13

Figure 13.1 Repair of an episiotomy/second-degree ­perineal tear. (A) The perineum prior to the repair; (B) continuous repair of the vaginal mucosa; (C) subcutaneous suture of the skin; (D) completed repair.
Figure 13.2 A right mediolateral episiotomy.
Figure 13.3 Ventouse/vacuum extractor cups. (A) Metal ventouse cup; (B) silicone rubber cup; (C) OmniCup™.
Figure 13.4 Kielland rotational forceps (left) and Simpson non-rotational forceps (right).
Figure 13.5 Application of forceps.
Figure 13.6 Uterine incisions for caesarean section. (A) Transverse lower segment incision; (B) classical caesarean section incision.

Chapter 14

Figure 14.1 The structured approach to managing obstetric emergencies.
Figure 14.2 Left lateral tilt. The pregnant woman is tilted to the left to move the pregnant uterus off the abdominal vessels, thus improving cardiac output. There are various methods of achieving this; many hospitals have special wedge shaped cushions, but pillows and blankets can be used.
Figure 14.3 The differential diagnosis of acute maternal collapse.
Figure 14.4 (A) Placental abruption with revealed haemorrhage; (B) placental abruption with concealed haemorrhage.
Figure 14.5 Placenta praevia.
Figure 14.6 Algorithm for the management of obstetric haemorrhage.
Figure 14.7 Cord prolapse. (A) Cord presentation: the cord is below the presenting party (head in this case but commonly a malpresentation) with the membranes intact; (B) cord prolapse: the membranes have ruptured and the cord is below the presenting part and has prolapsed into the vagina.
Figure 14.8 Shoulder dystocia. After delivery of the head, shoulder dystocia occurs due to the shoulders being unable to pass under the maternal symphysis pubis.
Figure 14.9 Algorithm for management of shoulder dystocia.
Figure 14.10 Uterine inversion.

Chapter 15

Figure 15.1 Involution of the uterus. (A) Day 1, 18 week sized uterus (just below the umbilicus); (B) day 7, 14 week sized uterus; (C) day 14, 12 week sized uterus. Uterus is larger following caesarean section and in multiparous women.
Figure 15.2 (A) Transanal ultrasound showing the anal mucosa and anterior disruption of the internal anal sphincter (dark band) following a third-degree tear at delivery; (B) diagrammatic representation of part A.
Figure 15.3 The breast during lactation.
Figure 15.4 (A) Poor positioning for breastfeeding; (B) good positioning.

Chapter 16

Figure 16.1 Components of neonatal care. CPAP, continuous positive airways pressure.