OBSTETRICS BY TEN TEACHERS SIXTEENTH EDITION EDITED BY GEOFFREY CHAMBERLAIN MD FRCS FRCOG FRACOG(Hon) ‘Co-published in the USA by Oxford University Press, Ine, New YorkFit published in Gres Britain 1917 8 Mido Elven dion pubed 19668 Ober Siacenth edition pubes 1995 by Edward Arno, ‘Third imprest 1997 by Arnold, member of the Hodder Hea Geoup 538 Euston Roa, London NW1 SBF, bse in the United States of America by Onlord University Pres, Inc 198 Madison Avenue, New York, NY10016 (Onford ea repisered trademark of Oxford University Pres © 1995 Edward Amold Allright reserved. No pat ofthis publication may be reproduced or ‘apn any fr or by ay tea cone or mechani, including photocopying, recording or any information storage or eevieval ‘stem, without ether peor permission in writing from the publisher oF 2 Tounce permitting restricted copying Ia the United Kingdom such lenees ae sued by the Copyright Licensing Agency: 99 Tettenham Cour Road, London W1P SHE, Whilst the advice and information in this book is believed tobe tue and accurate atthe dite of gong to pres, neither the author nor the publisher {an accept any legal esponsibility or lib for any ervrs or missions that maybe made In prcicular (os without limiting the generality ofthe preceding dslsimer) every efor: has been made 19 ceck drug dosages, TRowever ti stil posble that erors have en missed, Furthermore dosage schedules ate constantly being revised and new side effets [ecognived. For these reasons the reaer i srongly urge to consul the ‘drug companie’ printed instruction before administering any ofthe ‘drugs recommended inthis book Briss Library Cataloguing in Publication Data ‘A catalogue record fr this book is valle from the British Library Library of Congres Cataloging’ Publication Data ‘A catalog eecod for this book i available fom the Library of Congress ISBN 0340573189 Typeset in 10/11 Garamond by Weare, Boldon, Tyne and Wear Printed and bound in Gret Britain by The Bath Pres, BathCONTENTS LIST OF CONTRIBUTORS A HISTORY OF TEN TEACHERS IN OBSTETRICS PREFACE INTRODUCTION 1, ANATOMY AND PHYSIOLOGY ‘The early development of the ovum ‘Ovulation Formation of decidua Maturation of the ovum ‘Transit and fertilization of the Early development and embedding of the Blstocyst ‘The placenta, cord and membranes Functions of the placenta The chorion ‘The amnion Amniotic fluid The umbilical cord ‘The ferus Size of the fetus Fetal circulation Oxygen supply to the fetus Nuttion ofthe fetus Anatomy of the normal female pelvis and the fetal skull The pelvis ‘The fetal skull Maternal physiology Further reading 2. NORMAL PREGNANCY Clinical signs and diagnosis of pregnancy “The duration of pregnaney Symptoms of pregnancy Signs of pregnancy Head nchiaide goaiiceayhin levels Ultrasound diagnosis of pregnancy Differential diagnosis of pregnancy _ Pseudocyesis The expected date of delivery Ultrasound scan Antenatal care Pre-pregnancy counselling Antenatal care Antenatal fetal monitoring ‘Advice during pregnancy Harmful effects of drugs on the fetus Smoking during pregnancy Alcohol during pregnancy Obstetrical examination Abdominal examination Vaginal examination Ratlologieal examination Uhrasound examination in obstetrics Clinical applications of ultrasound Assessing fetal growth and size ‘The safety of ultrasound Prenatal diagnosis Further reading3. Contents ABNORMAL PREGNANCY Abnormalities of the pelvic organs Retroversion of the uterus Prolapse of the pregnant uterus Congental aboormalies of the uterus and vas Uterine fibroids Ovarian cysts Carcinoma of the cervix uteri Placental abnormalities Placental site, anatomy and. adherence ‘The umbilical cord Gestational trophoblastic disease Actiology Biological behaviour and histological classification Recognition of molar pregnancy Management Surveillance Treatment of gestational trophoblastic tumour ‘Chemotherapy Choice of chemotherapy Antepartum haemorrhage Placental abruption Placenta praevia Vasa praevia Polyhydramnios and oligohydramnios Polyhydramnios Oligohyéramnios ‘Ammiontc adhesions Hypertensive disorders in pregnancy Pregnancy induced hypertension Eclampsia Chronic hypertension preceding pregnaney Placental abruption and hypertension during pregnancy Intercurrent diseases during pregnancy Renal disease ‘Anaemia Heart disease Diabetes Infections during pregnancy Sexually transmitted diseases Diseases of the alimentary tract Neurological disease Endocrine disorders Paychiatrie disorders in pregnancy and the puerperium Drug dependence 110 1m 1 15, 19 122 126 131 134 136 136 138. 139 Puerperal disorders ‘The fetus at risk in late pregnancy Placental insufficiency during ntsuterine growth retardation Postmaturity Intrauterine death of the fetus Muleiple pregnancy Varieties of twins Counselling in obstetrics Diagnosis of intrauterine death or fetal abnormality Intrauterine death or termination due to abnormality Longer term follow up ‘The next pregnancy Fetal loss in early pregnancy ‘Abortion or miscarriage Pathological anatomy Clinical varieties of abortion stoic pregnancy ctiology Pathological anatomy Clinical course and management Other causes of haemorrhage during early pregnancy Further reading NORMAL LABOUR “The stages of normal labour ‘The onset of labour ‘The uterine segments ‘The stages of labour “The mechanism of normal labour Mechanism of labour with vertex presentations Management of normal labour Management of the frst stage Management of the second stage Delivery of the baby Management of the third stage ‘The relief of pain in labour ‘The ideal analgesic Spinal anaesthesia ‘Anaesthesia for caesarean section General anaesthesia in obstetric practice ‘Anaesthesia associated maternal mortality ‘The use of oxytocic drugs Further reading 139 140 ut MI 45 147 148 149 154 155 155 156 156 156 157 158. 162 162 162 163 165 165 167 167 167 168 168 173 174 178 179 183 183 185 187 188 189) 191 191 192 193 1945. ABNORMAL LABOUR Prolonged labour The partogram Fetal malposition and malpresentation ‘Occipitoposterior positions Deep transverse arrest of the head Face presentation Brow presentation Breech presentation Transverse and oblique lie Fetal malformations that cause difficulty in labour Pelvic abnormalities and disproportion Pelvic abnormalities Cephalopelvic disproportion Obstructed labour Premature labour and preterm premature rupture membranes Aetiology and diagnosis Prinsples of management Predicting and preventing preterm labour " Fetal distress during labour Continuous monitoring of the fetal heart rate Fetal scalp blood sampling ‘Traumatic lesions Rupture of the uterus ‘Acute inversion of the uterus Laceration of the cervi Laceration of the perineum and vagina Fistulae Haematoma of the vulva Broad ligament haematoma Mavernl neve injuries Postpartum haemorrhage Primary postpartum haemorrhage Secondary postpartum haemorrhage Shock in obstetrics Postpartum pituitary necrosis Further reading 6. NORMAL PUERPERIUM The puerperium The baby ‘The respiratory system at birth ‘The immediate care of the healthy infant 195 195 195 198 198 202 202 204 206 24 216 216 216 220 Ds. 226 226 226 27 29 29 233 234 234 237 238 238 239 240 240 241 241 241 245 245, 246 247 249 249 253 253 8. Contents Normal progress of the full term infant Infant feeding Breast or bottle feeding? Lactation Breastfeeding Difficulties in breastfeeding Artificial feeding Further reading ABNORMAL PUERPERIUM Puerperal pyrexia Genital eact infection Urinary tract infection Breast infection ‘Thrombophlebitis Wound infection Respiratory tract infection Intercurrent febrile illness Breast disorders in the puerperium Engorgement Cracked nipples Acute puerperal mastitis Breast abscess Inhibition of lactation Galactocoele Carcinoma of the lactation breast Disorders of haemostasis in pregnancy Haemostasis Coagulation and fbrinolye systems in pregnancy and labour Coagulation disorders specie 10 pregnancy and labour Coagulation disorders coincident with pregnancy ‘Thrombocytopaenia in pregnancy ‘Thromboembolic disease in pregnancy Further reading OBSTETRIC PROCEDURES External version Induction of labour Episiotomy Forceps delivery ‘Vacuum extractor (Ventouse) Internal version Caesarean section Further reading 258 259 260 260 263 263 264 266 267 267 267 270 271 271 va 21 Pa 21 271 272 273 273 273 273 274 274 278 278 280 280 283 284 285 285, 285, 288, 289 296, 297 297 3039. Contents PROBLEMS OF THE NEWBORN Resuscitation Low birthweight infants Very low weight infants Stabilizing the very low birth ‘weight infant Specific problems ‘Temperature control Respiratory problems Nutrition ‘Osteopenia of prematurity (rickets) Intraventricular haemorrhage and ischaemic brain injury Patent ductus arteriosus Infection Anaemia of prematurity Necrotizing enterocolitis Retinopathy of prematurity Grows Parents Discharge from hospital ‘Neurodevelopmental outcome ‘The asphyxiated infant Birth trauma Respiratory distress Jaundice in the newborn infant Infections Metabolic problems 305 305 309 310 310 3 3 312 314 315 315 316 317 317 318 318. 318. 318. 319 319 319 321 323, 325 328. 330 Hypoglycaemia Gastrointestinal problems ‘Vomiting iarrhoea Haematological problems Rhesus and ABO incompatibility Congenital malformations Lower limb malformations Further reading 10. MEDICO-LEGAL PROBLEMS IN OBSTETRICS. Litigation in obstetrics Pre-pregnancy and genetic counselling Pregnancy Labour and delivery The postnatal period Home confinement Further reading 11, VITAL STATISTICS Macernal mortality ths and neonatal deaths: Perinatal mortality Further reading Index 330 331 331 332 332 332 335, 34 342 343 343 344 345, 346 348, 348, 349 351 352 397 361 363LIST OF CONTRIBUTORS Mary Anderson FRCOG Consultant Obstetrician and Gynaecologist Lewisham Hospital, London Geoffrey Chamberlain MD FRCS FRCOG Formerly Professor of Obstetrics and Gynaecology, St George's Hospital Medical School, London ‘Tim Coltart PhD FRCS(Ed) FRCOG Consultant Obstetrician and Gynaecologist Guy's Hospital and Queen Charlotte's and Chelsea Hospital, London Gedis Grudzinskas MD FRCOG FRACOG Professor, Academic Unit of Obstetrics and Gynaecology, The Royal London Hospital and St Bartholomew’s Hospital, London Frank Loeffler FRCS FRCOG Consultant Obstetrician and Gynaccologist, St Mary's Hospital and Samaritan Hospital for Women, and Queen Charlotte's and. Chelsea Hospital, London Malcolm Pearce MD FRCS FRCOG Formerly Consultant Obstetrician St George’s Hospital, London Charles Rodeck DS FRCOG FRCPath Professor of Obstetrics and Gynaecology University College and Middlesex Schoo! of Medicine, London Mareus Setchell FRCS FRCOG Consultant Obstetrician and Gynaecologist Se Bartholomew's Hospital and Medical Director, Homerton Hospital, London Nick Siddle MRCOG Formerly Consultant Obstetrician and Gynaecologist, University College and Middlesex Hospitals, London Philip Steer MD FRCOG Professor of Obstetries and Gynaecology Chelsea and Westminster Hospital, London SPECIAL CHAPTERS CONTRIBUTED 8) Elizabeth Hopper RN, RM Dip Couns Sister in Charge, The Bereavement Unit St George's Hospital, London ‘Tom Lissauer MBChir, FRCP Consultant Paediatrician, St Mary’s Hospital London Barbara Morgan FFA RCS Consultant Anaesthetist, Queen Charlotte's and Chelsea Hospital, London Ruth Warwick MRCP FRCPath Consultant Haematologist, North London Blood ‘Transfusion Centre, London Ruth White MRCPsych MPhil Consultant Psychiatrist, The Warstock Lane Centre, Billesley, BirminghamA HISTORY OF TEN TEACHERS IN OBSTETRICS ‘The book was first published under the title Mid- wifery by Ten Teachers by Edward Arnold (Pub- lishers) “Ltd in 1917. Comyns Berkeley, a consultant obstetrician and gynaecologist on the staffs of the Middlesex Hospital, the City of London Lying-in Hospital and the Chelsea Hospi tal for Women provided the inspiration; he was the first Editor and Director and continued as such until the fifth edition in 1935, remaining in an editorial capacity until his death in 1942, ‘The aim was to produce a textbook for students ‘preparing for their final examination, and for others who have passed beyond the stage of exam- inations’. The original ten contributors, with experience as examiners, were all teachers who came from “eight general hospitals with medical schools and three large lying-in hospitals’, all in London. In order to achieve collective authorship, reflecting the views of all the teacher-contributors, the subjects were first portioned out among the ten ‘writers and their chapters were then ‘criticized, amended and partly rewritten’ at numerous meet” ings of alten. In 1948 the editors ‘insisted on close collaboration at all stages of composition so as to express the unanimous opinion of the ten authors; only on occasion was it necessary to accept the views of a majority’. To each author representa- tions and suggestions were made by the other nine “to assist him in the preparation of his manuscript. ‘The pace of life today has meant that more respon= sibility for the contents falls on the editors, but meetings of all ten teachers are still held at which contentious and debatable issues are raised. In a book which has gone through 16 editions spanning 76 yeas the subjects dealt with reflect the changing practice of obstetrics during this time. For instance in the second edition in 1920, a chapter on the new subject of ‘Ante-natal Hygiene’ and a short account of recently dis- covered ‘vitamines’ were added; in the third edi- tion in 1925 ‘several skiagrams were reproduced to emphasize the advances made in the application of photogeaphy to obstetric diagnosis’. In the fourth edition in 1931, “the time-honoured position of the management of labour with pelvic disproportion asa final lesson was discarded and put in its proper place’; new matter on the medical induction of labour and on blood transfusion was included. In the fifth edition in 1935, endocrinology was intro~ duced in relation to the physiology of menstrua- tion and the ovarian cycle. Illustrations of the lower segment caesarean section operation appeared for the first time in the sixth edition in 1938 when metric measures were inserted after the English ones throughout. The classification of abnormal pelves and their effect on labour, tonic retraction of the uterus in obstructed labour and the use of sulphonamides in obstetrics were new topics introduced in the seventh edition in 1942. ‘With every edition there has been the rewriting and rearrangement of chapters, and the removal of redundant material and repetitions, although dif- ferent points of view on subjects have been rerained. Illustrations have been removed and oth- crs substituted. Modern work has been included. Certain subjects such as pre-eclamptic toxaemia (pregnancy induced hypertension) appear in every edition but, with more recent information availablecach time, alteration has been necessary reflecting modern therapy and practice, Due notice was taken in preparing new editions of letters from students and obstetricians and of criticism in the medical press. The three prin ‘Comyns Berkeley in the first in the main, been adhered to. ‘First, that the book should be written for medical students and young practitioners; secondly that it expressed the col- lective view of the ten contributors; and thirdly, that all ten were actively engaged in teaching obstetries in the medical schools ‘of hospitals in London’ (ninth edition, 1955). However, in 1955 the editors decided that the section of the book devoted to the health and disease of the newborn infant should more properly be written by a paediatrician than by an obstetrician, and this has been the case in every edition since the In the eleventh edition in 1966 the title was changed to Obstetrics. The editors ‘regretted the loss of an English word but thought that the new tile was more in keeping with current usage’. They tried to describe modern obstetric practice and to keep abreast_of recent advances. in theoretical knowledge. They reduced the length of the chap- ters on major ‘mechanical complications of labour” although they did not completely eliminate those sections because some readers practised in coun- tries where adequate obstetric services were not generally available. ‘After more than 50 years of service to students and practitioners the plan of the contents was re- arranged. The twelfth edition in 1972 contained new chapters on Placental Insufficiency and Fetal Distress, Haemolytic Disease, Coagulation Dis- orders, Oxytocic Drugs and ‘Therapeutic Abor- tion. New topies such as amniocentesis, fetal Blood sampling, fetal heart monitoring, ultrasonies and prostaglandins were included By 1980 (thirteenth edition) it was considered that a third revolution in obstetric practice was taking place. The first was a gencral adoption of ower segment caesarean section. permitting safe intervention during labour, often in the fetal inter- est; the second was the overcoming of puerperal sepsis. This third phase meant the introduction of many new methods of assessing the state (or well- boing) of the fetus, prolonged Isbour was being prevented by the proper use of oxytocin and better relief of pain was being achieved with extradural anaesthesia, These advances were reflected by improvements in maternal and perinatal mortality. A History of Ten Teachers in Obstetrics xi While describing fully newer methods of obstetric ‘management, the editors took care to retain all that was good in carlier practice, underlining. the importance to students of a proper understanding af the principles on which eel decisions must depend. In 1990 (fifteenth edition) emphasis was placed con modern imaging techniques and the assessment of fetal well-being. Because of the inereasing ltiga- tion that was taking place in medicine generally, and in obstetrics in particular, a chapter on the medico-legal aspects of obstetrics was included. A haematologist wrote a chapter on coagulation dis- orders; a psychiatrist with a special interest in obstetrics wrote one on psychiatric disorders; and a paediatrician revised the paediatric section extensively ‘The fourteenth edition (1985) was published for the first time in paperback, though maintaining the size and shape of the old hardback. The fifteenth edition went even further by being published in paperback in a new size and shape. It was pub- lished also in the Educational Low-Priced Books Scheme funded by the Overseas Development ‘Administration as part of the British Government Overseas Aid Programme. During the 76 years of its existence Ten Teachers Mrdéwsfery/Obstetrcs has had 43 contributors, of whom 14 acted as editors. Six consultants wrote special chapters on their own subjects (paediatrics, psychiatric illness, blood coagulation and medico- legal problems). They have all played a part in achieving the undoubted success of the book, but pethaps three individual editors had more influ- fence on it than the rest. Comyns Berkeley master- minded the concept of a book based on the collaboration of ten London teachers from the foundation in 1917 until his death in 1942; Ereder- ick Roques turned awkward phrases from 1948 to 1961 into good English throughout the book; and Stanley Clayton made sure from 1955 to 1985 that ho statement was made by a contributor unless it had good scientific support. Thus was achieved a well-balanced and up-to-date view of current obstetric practice written with the senior medical student and young doctor in mind. TILT. Lewis 1995‘Ten Teachers 1917-1994 OBSTETRICS Name 9 10 "1 12 1B 4 15 16 °F Russell Andrews J.D. Barris “Conyers Berkeley Victor Bonney Harold Chapple G.F, Darwall Smith Stanley Dodd 9]. S. Fairbairn T.G. Stevens *Clifford White “Frank Cook Victor Lark Donald W. Roy “William Gilliatt Aubrey Goodwin Douglas MacLeod °A.J. Wrigley *Johin Beattie Humphrey Arthure Arthur C. H. Bell "Frederick W. Roques *Stanley Clayton A. Briant Evans C.M, Gwillim *T.L.T. Lewis Robert Percival “Donald Fraser Joseph M. Holmes Ian Jackson. *George Pinker Philip Rhodes D. W.T. Roberts Charles P. Douglas J.-M. Brudenell “Geoffrey Chamberlain Denys Fairweather 10 10 10 10 10 10 19 “ “4 “4 “4 4 “4 “4 4“ 15 15 15 15John C. Harigill Marcus Setchell Ronald W. Taylor Tim Coltart Gedis Grudzinskas Frank Loeffler Philip Steer Malcolm Pearce Nick Siddle Mary Anderson Charles Rodeck PAEDIATRICIANS Edward Hart R.J.K. Brown Dr R. Dinwiddie DrT. Lissauer SPECIAL CHAPTERS Margaret Christie-Brown Ruth White Mary Anderson G. Oppenheim Ruth Warwick Liz Hopper Barbara Morgan CONTRIBUTORS: SPECIAL CHAPTERS: “EDITORS 9 10 6 6 4 13 3 B 4 4 4 15 15 15 15 15 15 16PREFACE This is the longest standing English textbook in obstetrics. The sixteenth edition has been changed and adepted to help undergraduates and those working for the Diploma of the Royal College of Obstetricians and) Gynaecologists. We have brought in many new methods of obstetrical man- agement and our contents have changed in accord- ance with alterations in the London medical scene. ‘We thank all our contributors for their work in bringing this new edition to fruition. We have taken the opportunity of asking Mr T.LT. Lewis, the Editor Emeritus and. senior contributor t0 this series of volumes, to write a short history of the Obstetries by Ten Teachers. This we include for we think it would be of interest to students joining the subject who can feel they have some continuity with teaching back to the time of the First World War when this book was first published. We think that continuity in medicine is important and would like to pay tribute to the many previous editors and con- tributors of Obstetrics by Ten Teachers over its 80 years’ existence. ‘We have lost some contributors by retirement and moving from London teaching scene. We welcome their replacements, We are most grateful to all the production staff at Edward Arnold for their courtesy and prompt help in publishing tht Geoffrey Chamberlain London 1995INTRODUCTION ‘The woman expecting her baby in the 1990s is very different from the patients the student may have inet in other branches of medicine, The pregnant woman is young and fit, while many others they have met are patients who are older and have disease processes. Most women in the obstetric scene have no disease and are going through a physiological process. This, however, can alter tharply t pathology and the borderline between the two must be watched carefully by obstetricians and midwives. Modern women having babies are much better informed than they were years ago. They want to know more about what is happening and they and their partners have the right to be kept in the picture. This is not just a feminist fad but common sense, for the woman who knows what is likely to happen will be better prepared for actions in late pregnancy and labour. The mind is acutely attuned during pregnancy to Iistening to others. Among those who provide the woman with true informa- tion and sound ideas must be the professionals as well as the market-place, the magazines and broad- casting that often feed the extremes of thought. It is for everyone in obstetrics, from the professor to the medical student, to help to support women and their partners during the antenatal period, bringin them to the Highest preparation in body and mind to the time of childbirth. Most. people outside obstetrics consider the essential part of having a baby is childbirth; this isa great event of a new life coming into the world. However, professionals know that life actually started some 38 weeks before this at conception. A tnost important part of obstetrics is the antenatal period and the care given then, Hf this goes well, it fix remove many af the problenuiof childbirth and ensure an easier, happier and safer time at birth for both mother and baby. It is further probable that many postnatal influences are laid down in the fetus inside the uterus. This does not just apply to the genetic changes associated with chromosomal tnomaly but to the functional structare and nutri- tion of the fetus as it grows. For example, the biggest single independent variable for raised blood pressure in the 50 to 60 year-old man is his birth weight and its ratio to placental weight, a measure of what happened inside the uterus Between 14 and 20 weeks of gestation, This is more important than any of the subsequent factors that people pay so much attention to such as diet, high ind low density lipoproteins and exercise. The nutrition of the mother and so of the fetus inside the uterus is the major feature affecting blood pressure (and therefore coronary artery disease and stroke), obstructive respiratory disease, clot- ting factors and the non-insulin dependent diabe- resin older age. Intranterine life is the most important time of existence and research i now being carried out intensively in this area, All who would wish to study obstetrics must ay great attention to the antenatal period for it Bio ica tindesinvesr ace and teégimental aren until the 1990s. If good antenatal care is carried ‘ut, then the woman will avoid some of the major problems that can make later pregnancy andxvi Introduction labour hazardous. She will come to labour better have a relatively painfree delivery of a healthy prepared and with all the methods of modern baby. sia available for her choosing, will be able to1 ANATOMY AND PHYSIOLOGY THE EARLY DEVELOPMENT OF THE OVUM An oocyte is released from the ovary during most normal menstrual cycles. The eyele is described in two phases: the first half is known as the follicular or proliferative phase, during which the ovarian follicle enlarges and becomes distended with fluid. On about the 14th day of the cycle the follicle discharges an oocyte into the uterine (Fallopian) tube. The sec- cond half of the cycle is known as the luteal or secretory phase. In this phase the cells of the empty fallicle become swollen with yellow lipid, and the follicle is now called the corpus lteum During the follicular phase the cells lining the follicle secrete oestrogens which cause prolifera- tion of the glands and stroma of the endometrium. During the luteal phase the cells of the corpus Juteum secrete both oestrogens and progesterone, and the combined action of these hormones causes further proliferation of the endometrium and also secretion of sugars, amino acids, mucus and enzymes by the endometrial glands. The endomet- rium reaches its maximum development in the late luteal phase, forming a decidua into which the oocyte, if it is fertilized, can embed, The complex hormonal control and details of the anatomical changes in the ovary and endomet- rium during the menstrual cycle are described in Gynaecology by Ten Teachers. OVULATION In the 4th week of life germ cells migrate from the wall of the yolk sac to an area of mesenchyme on the posterior wall of the coclom. These form the primordial germ cells, which give rise to numerous rimary oocytes, large round cells with relatively large, chromatin-rich nuclei. The primary oocytes become surrounded by a single layer of smaller flattened cells to form primordial follicles. At birch each ovary contains up to 2 million follicles, although many are lost before the menarche. ‘THE OVARIAN FOLLICLE, ‘During maturation of the follicle the flat cells that surround the primordial ovum multiply, become rounded and arranged in several layers (the gramu- losa cells). Their growth is eccentric, so that the oocyte comes to lie at one side of the mass of granulosa cells, and eventually clear fluid appears among these cells, so that a follicle is formed with the oocyte placed to one side (see Fig. 1.1). The clump of granulosa cells that is directly related to the oocyte forms a hillock (the cums) that projects into the cavity of the follicle, and at this. stage the oocyte is surrounded by a'clear mem- brane, the zona pellucida, within which it can rotate. The granulosa cells that are immediately related to the zona pellucida become arranged in a