Obstetrics

Obstetrician

Occupation
Names	Doctor, consultant, medical specialist
Occupation type	Specialty
Activity sectors	Medicine and surgery
Description
Competencies	Physician (D.O. or M.D.)
Education required	Medical training and specialised postgraduate training

Obstetrics (from the Latin obstare, "to stand by") is the medical specialty dealing with the care of all women's reproductive tracts and their children during pregnancy (prenatal period), childbirth and the postnatal period. Many obstetricians are also gynecologists, meaning they perform in both specialties. In the United States, these physicians are commonly referred to as OB/GYNs.

History of obstetrics

Prior to the 18th century, caring for pregnant women in Europe was confined exclusively to women, and rigorously excluded men. The expectant mother would invite close female friends and family members to her home to keep her company.^[1] Skilled midwives managed all aspects of the labour and delivery. The presence of physicians and surgeons was very rare and only occurred once a serious complication had taken place and the midwife had exhausted all measures to manage the complication. Calling a surgeon was very much a last resort and having men deliver women in this era whatsoever was seen as offending female modesty.^{[2] [3]}

18th century

The 18th century marked the beginning of many advances in European midwifery. These advances in knowledge were mainly regarding the physiology of pregnancy and labour. By the end of the century the anatomy of the uterus and the physiological changes that take place during labour began to be understood by medical communities. The introduction of forceps in childbirth also took place during the 18th century. All of these medical advances in the knowledge of obstetrics would be the lever for the introduction of men into an arena that had only ever been managed and run by women, midwifery.^[4]

The addition of the male-midwife is historically a significant change to the profession of obstetrics. In the 18th century medical men began to train in area of childbirth and believed with their advanced knowledge in anatomy that childbirth could be improved. In France these male-midwives were referred to as "accoucheurs". This title was later on lent to male-midwives all over Europe. The founding of lying-hospitals also contributed to the medicalization and male-dominance of obstetrics. These lying-hospitals were establishments where women would come to have their babies delivered, which had prior been unheard of since the midwife normally came to home of the pregnant woman. This institution provided male-midwives or accoucheurs with an endless number of patients to practice their techniques on and also was a way for these men to demonstrate their knowledge.^[5]

Many midwives of the time bitterly opposed the involvement of men in childbirth. Some male practitioners also opposed the involvement of medical men like themselves in midwifery, and even went as far as to say that men-midwives only undertook midwifery solely for perverse erotic satisfaction. The accoucheurs argued that their involvement in midwifery was to improve the process of childbirth. These men also believed that obstetrics would forge ahead and continue to strengthen.^[2]

19th century

Even though it was expected in the 18th century that obstetrics would continue to grow, the opposite showed to be true. Obstetrics entered a stage of stagnation in the 19th century, until about the 1880s.^[1] The central explanation for the lack of advancement during this time was substantially due to the rejection of obstetrics by the medical community. The 19th century marked an era of medical reform in Europe and increased regulation over the medical profession. Major European institutions such as The College of Physicians and Surgeons considered delivering babies ungentlemanly work and refused to have anything to do with childbirth as a whole. Even when Medical Act 1858 was introduced, which stated that medical students could qualify as doctors, midwifery was entirely ignored. This made it nearly impossible to pursue an education in midwifery and also have the recognition of being a doctor or surgeon. Obstetrics was pushed to the side.^[6]

By the late 19th century the foundation of modern day obstetrics and midwifery began to be laid. The delivery of babies by doctors became popular and readily accepted but midwives also continued to play a role in childbirth. Midwifery also changed during this era due to increased regulation and the eventual need for midwives to become certified. Many European countries by the late 19th century were monitoring the training of midwives and issued certification based on competency. Midwives were no longer uneducated in the formal sense.^[7]

As midwifery began to develop so did the profession of obstetrics near the end of the century. Childbirth was no longer unjustifiably despised by the medical community as it once had been at the beginning of the century. But the specialty was still behind in its development stages in comparison to other medical specialities, and remained a generality in this era. Many male physicians would deliver children but very few would have referred to themselves as obstetricians. The end of the 19th century did mark a significant accomplishment in the profession with the advancements in asepsis and anesthesia which paved the way for the mainstream introduction and later success of the Caesarean Section.^[7][8]

Before the 1880s mortality rates in lying-hospitals would reach unacceptably high levels and became an area of public concern. Much of these maternal deaths were due to Puerperal fever, at the time commonly known as childbed fever. In the 1800s Dr. Ignaz Semmelweis noticed that women giving birth at home had a much lower incidence of childbed fever than those giving birth by physicians in lying-hospitals. His investigation discovered that washing hands with an antiseptic solution before a delivery reduced childbed fever fatalities by 90%.^[9] So it was concluded that it was physicians who had been spreading disease from one laboring mother to the next. Despite the publication of this information, doctors still would not wash. It was not until the 20th century when advancements in aseptic technique and the understanding of disease would play a significant role in the decrease of maternal mortality rates among many populations.

Prenatal care

Prenatal care is important in screening for various complications of pregnancy. This includes routine office visits with physical exams and routine lab tests:

• 

  3D ultrasound of 3-inch (76 mm) fetus (about 14 weeks gestational age)

• 

  Fetus at 17 weeks

• 

  Fetus at 20 weeks

First trimester

• Complete blood count (CBC)
• Blood type
• General antibody screen (indirect Coombs test) for HDN
  • Rh D negative antenatal patients should receive RhoGam at 28 weeks to prevent Rh disease.
• Rapid plasma reagin (RPR) to screen for syphilis
• Rubella antibody screen
• Hepatitis B surface antigen
• Gonorrhea and Chlamydia culture
• PPD for tuberculosis
• Pap smear
• Urinalysis and culture
• HIV screen
• Group B Streptococcus screen – will receive IV penicillin or ampicillin (it is much cheaper and has a wider coverage)if positive (if mother is allergic, alternative therapies include IV clindamycin or IV vancomycin)

genetic screening for downs syndrome (trisomy 21) and trisomy 18 the national standard in the United States is rapidly evolving away from the AFP-Quad screen for downs syndrome- done typically in the second trimester at 16–18 weeks. The newer integrated screen (formerly called F.A.S.T.E.R for First And Second Trimester Early Results) can be done at 10 plus weeks to 13 plus weeks with an ultrasound of the fetal neck (thick skin is bad) and two chemicals (analytes) Papp-a and bhcg (pregnancy hormone level itself). It gives an accurate risk profile very early. There is a second blood screen at 15 to 20 weeks which refines the risk more accurately. The cost is higher than an "AFP-quad" screen due to the ultrasound and second blood test but it is quoted to have a 93% pick up rate as opposed to 88% for the standard AFP/QS. This is an evolving standard of care in the United States.

Second trimester

• MSAFP/quad. screen (four simultaneous blood tests) (maternal serum alpha-fetoprotein; inhibin; estriol; bhcg or free bhcg) - elevations, low numbers or odd patterns correlate with neural tube defect risk and increased risks of trisomy 18 or trisomy 21
• Ultrasound either abdominal or trannsvaginal to assess cervix, placenta, fluid and baby
• Amniocentesis is the national standard (in what country) for women over 35 or who reach 35 by mid pregnancy or who are at increased risk by family history or prior birth history.

Third trimester

• Hematocrit (if low, mother will receive iron supplementation)
• Glucose loading test (GLT) - screens for gestational diabetes; if > 140 mg/dL, a glucose tolerance test (GTT) is administered; a fasting glucose > 105 mg/dL suggests gestational diabetes.

Most doctors do a sugar load in a drink form of 50 grams of glucose in cola, lime or orange and draw blood an hour later (plus or minus 5 minutes) ; the standard modified criteria have been lowered to 135 since the late 1980s

Antenatal record

On the first visit to her obstetrician or midwife, the pregnant woman is asked to carry out the antenatal record, which constitutes a medical history and physical examination. On subsequent visits, the gestational age (GA) is rechecked with each visit.

Symphysis-fundal height (SFH; in cm) should equal gestational age after 20 weeks of gestation, and the fetal growth should be plotted on a curve during the antenatal visits. The fetus is palpated by the midwife or obstetrician using Leopold maneuver to determine the position of the baby. Blood pressure should also be monitored, and may be up to 140/90 in normal pregnancies. High blood pressure indicates hypertension and possibly pre-eclampsia, if severe swelling (edema) and spilled protein in the urine are also present.

Fetal screening is also used to help assess the viability of the fetus, as well as congenital problems. Genetic counseling is often offered for families who may be at an increased risk to have a child with a genetic condition. Amniocentesis, which is usually performed between 15 and 20 weeks,^[10] to check for Down syndrome, other chromosome abnormalities or other conditions in the fetus, is sometimes offered to women who are at increased risk due to factors such as older age, previous affected pregnancies or family history.

Even earlier than amniocentesis is performed, the mother may undergo the triple test, nuchal screening, nasal bone, alpha-fetoprotein screening, Chorionic villus sampling, and also to check for disorders such as Down Syndrome. Amniocentesis is a prenatal genetic screening of the fetus, which involves inserting a needle through the mother's abdominal wall and uterine wall, to extract fetal DNA from the amniotic fluid. There is a risk of miscarriage and fetal injury with amniocentesis because it involves penetrating the uterus with the baby still in utero.

Imaging

Imaging is another important way to monitor a pregnancy. The mother and fetus are also usually imaged in the first trimester of pregnancy. This is done to predict problems with the mother; confirm that a pregnancy is present inside the uterus; estimate the gestational age; determine the number of fetuses and placentae; evaluate for an ectopic pregnancy and first trimester bleeding; and assess for early signs of anomalies.

X-rays and computerized tomography (CT) are not used, especially in the first trimester, due to the ionizing radiation, which has teratogenic effects on the fetus. No effects of magnetic resonance imaging (MRI) on the fetus have been demonstrated,^[11] but this technique is too expensive for routine observation. Instead, obstetric ultrasonography is the imaging method of choice in the first trimester and throughout the pregnancy, because it emits no radiation, is portable, and allows for realtime imaging.

Ultrasound imaging may be done at any time throughout the pregnancy, but usually happens at the 12th week (dating scan) and the 20th week (detailed scan).

A normal gestation would reveal a gestational sac, yolk sac, and fetal pole. The gestational age can be assessed by evaluating the mean gestational sac diameter (MGD) before week 6, and the crown-rump length after week 6. Multiple gestation is evaluated by the number of placentae and amniotic sacs present.

Fetal assessments

Obstetric ultrasonography is routinely used for dating the gestational age of a pregnancy from the size of the fetus, the most accurate dating being in first trimester before the growth of the fetus has been significantly influenced by other factors. Ultrasound is also used for detecting congenital anomalies (or other fetal anomalies) and determining the biophysical profiles (BPP), which are generally easier to detect in the second trimester when the fetal structures are larger and more developed. Specialised ultrasound equipment can also evaluate the blood flow velocity in the umbilical cord, looking to detect a decrease/absence/reversal or diastolic blood flow in the umbilical artery.

Other tools used for assessment include:

• Fetal karyotype can be used for the screening of genetic diseases. This can be obtained via amniocentesis or chorionic villus sampling (CVS)
• Fetal hematocrit for the assessment of fetal anemia, Rh isoimmunization, or hydrops can be determined by percutaneous umbilical blood sampling (PUBS) which is done by placing a needle through the abdomen into the uterus and taking a portion of the umbilical cord.
• Fetal lung maturity is associated with how much surfactant the fetus is producing. Reduced production of surfactant indicates decreased lung maturity and is a high risk factor for infant respiratory distress syndrome. Typically a lecithin:sphingomyelin ratio greater than 1.5 is associated with increased lung maturity.
• Nonstress test (NST) for fetal heart rate
• Oxytocin challenge test

Complications and emergencies

The main emergencies include:

• Ectopic pregnancy is when an embryo implants in the Fallopian tube or (rarely) on the ovary or inside the peritoneal cavity. This may cause massive internal bleeding.
• Pre-eclampsia is a disease which is defined by a combination of signs and symptoms that are related to maternal hypertension. The cause is unknown, and markers are being sought to predict its development from the earliest stages of pregnancy. Some unknown factors cause vascular damage in the endothelium, causing hypertension. If severe, it progresses to eclampsia, where convulsions occur, which can be fatal. Preeclamptic patients with the HELLP syndrome show liver failure and Disseminated intravascular coagulation (DIC).
• Placental abruption where the patient can bleed to death if not managed appropriately.
• Fetal distress where the fetus is getting compromised in the uterine environment.
• Shoulder dystocia where one of the fetus' shoulders becomes stuck during vaginal birth, especially in macrosomic babies of diabetic mothers.
• Uterine rupture can occur during obstructed labor and endangered fetal and maternal life.
• Prolapsed cord refers to the prolapse of the fetal cord during labor with the risk of fetal suffocation.
• Obstetrical hemorrhage may be due to a number of factors such as placenta previa, uterine rupture or tears, uterine atony, retained placenta or placental fragments, or bleeding disorders.
• Puerperal sepsis is a progressed infection of the uterus during or after labor.

Intercurrent diseases

In addition to complications of pregnancy that can arise, a pregnant woman may have intercurrent diseases, that is, other diseases or conditions (not directly caused by the pregnancy) that may become worse or be a potential risk to the pregnancy.

• Diabetes mellitus and pregnancy deals with the interactions of diabetes mellitus (not restricted to gestational diabetes) and pregnancy. Risks for the child include miscarriage, growth restriction, growth acceleration, fetal obesity (macrosomia), polyhydramnios and birth defects.
• Systemic lupus erythematosus and pregnancy confers an increased rate of fetal death in utero and spontaneous abortion (miscarriage), as well as of neonatal lupus.
• Thyroid disease in pregnancy can, if uncorrected, cause adverse effects on fetal and maternal well-being. The deleterious effects of thyroid dysfunction can also extend beyond pregnancy and delivery to affect neurointellectual development in the early life of the child. Demand for thyroid hormones is increased during pregnancy which may cause a previously unnoticed thyroid disorder to worsen.
• Hypercoagulability in pregnancy is the propensity of pregnant women to develop thrombosis (blood clots). Pregnancy itself is a factor of hypercoagulability (pregnancy-induced hypercoagulability), as a physiologically adaptive mechanism to prevent post partum bleeding.^[12] However, when combined with an additional underlying hypercoagulable states, the risk of thrombosis or embolism may become substantial.^[12]

Childbirth

Induction

Induction is a method of artificially or prematurely stimulating labour in a woman. Reasons to induce can include pre-eclampsia, placental malfunction, intrauterine growth retardation,^[13] and other various general medical conditions, such as renal disease. Induction may occur any time after 34 weeks of gestation if the risk to the fetus or mother is greater than the risk of delivering a premature fetus regardless of lung maturity.

Induction may be achieved via several methods:

• Pessary of Prostin cream, prostaglandin E₂
• Intravaginal or oral administration of misoprostol
• Cervical insertion of a 30-mL Foley catheter
• Rupturing the amniotic membranes
• Intravenous infusion of synthetic oxytocin (Pitocin or Syntocinon)

Labor

During labor itself, the obstetrician may be called on to do a number of tasks. These tasks can include:

• Monitor the progress of labor, by reviewing the nursing chart, performing vaginal examination, and assessing the trace produced by a fetal monitoring device (the cardiotocograph)
• Accelerate the progress of labor by infusion of the hormone oxytocin
• Provide pain relief, either by nitrous oxide, opiates, or by epidural anesthesia done by anaesthestists, an anesthesiologist, or a nurse anesthetist.
• Surgically assisting labor, by forceps or the Ventouse (a suction cap applied to the fetus' head)
• Caesarean section, if there is an associated risk with vaginal delivery, as such fetal or maternal compromise supported by evidence and literature. Caesarean section can either be elective, that is, arranged before labor, or decided during labor as an alternative to hours of waiting. True "emergency" Cesarean sections include abruptio placenta, and are more common in multigravid patients, or patients attempting a Vaginal Birth After Caeserean section (VBAC).

Postnatal care

Postnatal care is care provided to the mother following parturition.

A woman in the Western world who is delivering in a hospital may leave the hospital as soon as she is medically stable and chooses to leave, which can be as early as a few hours postpartum, though the average for spontaneous vaginal delivery (SVD) is 1–2 days, and the average caesarean section postnatal stay is 3–4 days.

During this time the mother is monitored for bleeding, bowel and bladder function, and baby care. The infant's health is also monitored.^[14]

Certain things must be kept in mind as the physician proceeds with the post-natal care.

1. General Condition of the patient.
2. Check for Vital Signs (Pulse, Blood Pressure, Temperature, Respiratory Rate, (Pain) at times)
3. Palor?
4. Edema?
5. Dehydration?
6. Fundus (height following parturition, and the feel of the fundus) (Per Abdominal Examination)
7. If an Episiotomy or a C-Section was performed, check for the dressing. Intact, pus, oozing, haematomas?
8. Lochia (colour, amount, odour)?
9. Bladder (keep the patient catheterized for 12 hours following local anaesthesia and 24–48 hours after general anaesthesia) ? (check for bladder function)
10. Bowel Movements?
11. More bowel movements?
12. Follow up with the neonate to check if they are healthy.

Surgery

The main surgical procedure performed in obstetrics is Cesarean section. However, obstetric surgery can potentially also include fetal surgery.

Salary

The salary of an obstetrician varies by country. In the United States, the salary ranges from $200,000 to $339,738.

Country	Annual salary (US$)
United Kingdom	187,771[15]
United Arab Emirates	231,809[16]
United States	226,369

See also

Wikimedia Commons has media related to Obstetrics.

• Childbirth and obstetrics in antiquity
• Gynecologist
• Henry Jacques Garrigues, who introduced antiseptic obstetrics to North America
• Maternal-fetal medicine
• Obstetric ultrasonography
• Puerperum

References

Further reading

• Lane, J (July 1987). "A provincial surgeon and his obstetric practice: Thomas W. Jones of Henley-in-Arden, 1764-1846". Medical History 31 (3): 333–48. PMC 1139744. PMID 3306222. 
• Stockham, Alice B. Tokology. A Book for Every Woman. o.O., (Kessinger Publishing) o.J. Reprint of Revised Edition Chicago, Alice B. Stockham & Co. 1891 (first edition 1886). ISBN 1-4179-4001-8

External links

• Ingenious - Archive of historical images related to obstetrics, gynaecology, and contraception.
• World Congress on Controversies in Obstetrics, Gynecology & Infertility (COGI)

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