Obstetrics

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Obstetrician
Occupation
NamesDoctor, consultant, medical specialist
Occupation type
Specialty
Activity sectors
Medicine and surgery
Description
CompetenciesPhysician (D.O. or M.D.)
Education required
Medical training and specialised postgraduate training
 
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Obstetrician
Occupation
NamesDoctor, consultant, medical specialist
Occupation type
Specialty
Activity sectors
Medicine and surgery
Description
CompetenciesPhysician (D.O. or M.D.)
Education required
Medical training and specialised postgraduate training

Obstetrics (from the Latin obstare, "to stand by") is the branch of the health sciences dealing with the care of women throughout pregnancy, including before birth, during birth, and in the period following birth.[1] The health professionals specializing in obstetrics are the obstetrician-gynecologist, the midwife (obstetrics), and the nurse midwife.

Prenatal care[edit]

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

First trimester[edit]

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[edit]

Third trimester[edit]

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[edit]

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,[2] 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[edit]

A dating scan at 12 weeks.

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,[3] 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[edit]

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:

Complications and emergencies[edit]

The main emergencies include:

Intercurrent diseases[edit]

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.

Childbirth[edit]

Induction[edit]

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,[5] 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:

Labor[edit]

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

Postnatal care[edit]

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.[6]

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[edit]

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

History[edit]

Two midwives assisting a woman in labour on a birth chair in the 16th century, from a work by Eucharius Rößlin.

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.[7] Skilledmidwives 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.[8] [9]

18th century[edit]

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.[10]

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.[11]

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.[8]

19th century[edit]

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.[7] 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.[12]

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.[13]

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 anesthesiawhich paved the way for the mainstream introduction and later success of the Caesarean Section.[13][14]

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%.[15] 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.

Salary[edit]

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

CountryAnnual salary (US$)
United Kingdom187,771[16]
United Arab Emirates231,809[17]
United States226,369

See also[edit]

References[edit]

  1. ^ Miller-Keane Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health. Saunders. 2005. ISBN 9781416026044. 
  2. ^ http://www.medicinenet.com/amniocentesis/article.htm
  3. ^ Ibrahim A. Alorainy, Fahad B. Albadr, Abdullah H. Abujamea (2006). "Attitude towards MRI safety during pregnancy". Ann Saudi Med 26 (4): 306–9. PMID 16885635. 
  4. ^ a b Page 264 in: Gresele, Paolo (2008). Platelets in hematologic and cardiovascular disorders: a clinical handbook. Cambridge, UK: Cambridge University Press. ISBN 0-521-88115-3. 
  5. ^ Wagner, Marsden. Born in the USA: How a Broken Maternity System Must Be Fixed to Put Women and Children First. Berkeley: University of California Press, 2006. Print.
  6. ^ "With Women, Midwives Experiences: from Shiftwork to Continuity of Care, David Vernon, Australian College of Midwives, Canberra, 2007 ISBN 978-0-9751674-5-8, p17f
  7. ^ a b Gelis, Jacues. History of Childbirth. Boston: Northern University Press, 1991: 96-98
  8. ^ a b Bynum, W.F., & Porter, Roy, eds. Companion Encyclopedia of the History of Medicine. London and New York: Routledge, 1993: 1050-1051.
  9. ^ Carr, Ian., “University of Manitoba: Women’s Health.” May 2000, accessed May 20, 2012, http://www.neonatology.org/pdf/dyingtohaveababy.pdf
  10. ^ Bynum, W.F., & Porter, Roy, eds. Companion Encyclopedia of the History of Medicine. London and New York: Routledge, 1993: 1051-1052.
  11. ^ Encyclopedia of Children and Childhood in History and Society, “Obstetrics and Midwifery.” accessed May 21, 2012, http://www.faqs.org/childhood/Me-Pa/Obstetrics-and- Midwifery.html
  12. ^ Bynum, W.F., & Porter, Roy, eds. Companion Encyclopedia of the History of Medicine. London and New York: Routledge, 1993: 1053-1055.
  13. ^ a b Drife, J., “The start of life: a history of obstetrics,” Postgraduate Medical Journal 78 (2002): 311-315, accessed May 21, 2012. doi: 10.1136/pmj.78.919.311.
  14. ^ Low, James., “Caesarean section-past and present,” Journal of obstetrics and gynecology canada 31, no. 12 (2009): 1131-1136, accessed May 20, 2012. http://www.sogc.org/jogc/abstracts/full/200912_Obstetrics_2.pdf
  15. ^ Caplan, Caralee E. (1995). "The Childbed Fever Mystery and the Meaning of Medical Journalism". McGill Journal of Medicine 1 (1). 
  16. ^ Obstetrician working in United Kingdom, UK Salary, SalaryExpert.com, Retrieved on 2009-03-23
  17. ^ Obstetrician working in United Arab Emirates, SalaryExpert.com. Retrieved on 2009-03-23

Further reading[edit]

External links[edit]