Obstetric medicine

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Obstetric medicine, similar to maternal medicine, is a sub-specialty of general internal medicine and obstetrics that specializes in process of prevention, diagnosing, and treating medical disorders in with pregnant women. [1] It is closely related to the specialty of maternal-fetal medicine, although obstetric medicine does not directly care for the fetus. The practice of obstetric medicine, or previously known as "obstetric intervention," primarily consisted of the extraction of the baby during instances of duress, such as obstructed labor or if the baby was positioned in breech. [2]

Contents

Obstetric physicians may provide care for chronic medical conditions that precede the pregnancy (such as epilepsy, asthma or heart disease), or for new medical problems that develop while the pregnancy is already in progress (such as gestational diabetes, and hypertension). [1] By the 19th century, obstetrics had become recognized as a medical discipline in Europe and the United States. [3] Formal training in obstetric medicine is currently offered in Australia, New Zealand, the United States, and Canada.

History and current status

Obstetrics gains its origins from the observation that, throughout historical record, women have accompanied other women during the birthing stage of their pregnancy. Similar findings can be observed in Anthropological research of tribal birthing practices, ancient Egyptian depictions, and even scriptures in the Old Testament [4] illustrate the presence of a woman figure, be it doctor or relative, present among the birthing of a baby.

During the 17th century, doctors were weary about the connection between midwifery and medicine, and thus failed to acknowledge its credibility. The practice of women assisting women through labor was viewed as uneducated. [5] However, as time progressed, a new perspective among pregnant patients grew, where by they sought for mid-wives to deliver their babies. For example, [5] in Wales and England, under 1% of people delivered their babies at home, which was a testament to the rise of midwives, that led to the present day professional field of Obstetrics. The roles of physicians in the process in delivering babies expanded as 17th century aristocrats utilized the best medical practitioners they could find. [3]

Obstetrics in the 1900s

During this period, the medical field was still grappling with the idea of obstetrics and midwifery, which were activities thought to be practiced by uneducated females, as they were unable to form a connection between medicine and midwifery. These circumstances led to the mistreatment of pregnant women, who were often made to partake in experimental procedures and untested treatments, which led to harm on mothers and the fetus.

Midwife Act 1902

The purpose of the act was to improve training for midwives as well as regulating their practice. [6] This meant that women who wanted to identify as "midwives" had to do so under the certification and verification of the Act. Penalties would incur on women who fraudulently claimed certification, with imprisonment possibly going up to 12 months. The caveat to this act was that a woman could practically engage in midwife duties, however they could not give them self the title of midwife or imply that they were affiliated with the title. However, the basis of the act was the acknowledgement of the field, creating an environment for people to gain professional knowledge about the field. This act was significant in leading to the present practice of obstetric medicine as it created a pathway for women to begin practicing with pre/post natal care, leading to the discovery of numerous methods in obstetric medicine.

Lack of access

Maternal mortality is an ongoing issue that is rising among pregnant women. A challenge facing many pregnant women is the lack of access to specialized obstetric care, often resulting in untimely deaths and an increasing rate of maternal morbidity. This lack of access offered to women has resulted in an outreach programs attempted by clinicians to reach women who are currently suffering from the consequences of reduced accessibility. This increased awareness is emerging during a time of "obstetric transition", [7] where research is noticing a notable shift in patterns from instances of high maternal mortality to patterns of lower maternal mortality. These patterns depict instances of high maternal mortality associated with implicit obstetric cause, while instances of low maternal mortality are related to factors such as maternal age, non-communicable disease (NCD) and indirect causes of maternal death (not directly linked to obstetric care).

The total cost of having a child in a hospital is can total several thousand dollars, which can be an expensive hurdle depending on an individual's socioeconomic status. Many countries lack the funding required to provide women from low-income households with prenatal care needs. This poses a problem for many women who are uninsured, or do not have access to adequate insurance. For women who are completely uninsured, their only source of prenatal care can be from charities and programs run by public funds, which is not a reliable source of prenatal care that has to be done regularly. [8] When considering couples who have children in their early 20s, with an annual income of $19,800, having a child that on average costs $4,800, [8] is a financial burden. Numerous insurance companies do not cover maternity care, which indicates that possessing insurance does not immediately clear couples of debt.

Medicine and tools

Forceps Obstetric forceps, Vachers Wellcome M0001481.jpg
Forceps

Early obstetrics

During the 18th century, common methods of resolving obstructed labor often resulted in high mortality of the infant. These methods included pulling on the legs of the baby or using breeching hooks. William Smellie revolutionized child birth by writing works on how to use forceps in the assistance if childbirth. [9] The practice of using forceps proved to be much more effective and less damaging to the baby.

Medication

By the 20th century, medicinal drugs were used to treat pregnant women, or to provide them with prenatal care. By the 1950s, women were having given contraceptive pills to begin regulating their hormones and fertility, [3] which effectively allowed couples to have planned pregnancies. By the 21st century, women were being given medication for the induction and augmentation of labor. 

Common ailments

Treating the ailments of pregnant mothers requires a unique approach, since medicines commonly used may have an adverse effect on the fetus. Some common ailments include, but are not limited to :

Postpartum depression

A common ailment of pregnant women is postpartum depression. Depression can cause pregnant women to have poor nutrition or inadequate strength to nurture herself and her baby. The result of this can be problems in development and health of the fetus. The use of medicine to treat postpartum depression is a subject for debate, since some research indicates that the use of antidepressants during pregnancy can lead to physical malformations and long-term health problems of the baby [10] Other forms of treatment include support groups and psychotherapy.

Gestational diabetes

Gestational diabetes is observed by elevated glucose levels in pregnant women who have never had diabetes. This form of diabetes occurs when placental hormones interfere with insulin produced by the mother, resulting in an excess of glucose in the blood. The excess glucose will cross the placenta and cause the baby's pancreas to produce extra insulin and store the excess glucose as fat. [11] Gestational diabetes is treated by a diet and exercise regiment the goal of maintaining lower levels of glucose in the body. [12]

Hypertension

Gestational hypertension is characterized by high blood pressure during pregnancy. Chronic hypertension can lead to a severe condition called preeclampsia, which can result in damage to organs. Hypertension can cause the placenta to not receive enough blood and starving the fetus of oxygen. Hypertension is treated in pregnant mothers by adjusting their diet to contain less fat and salt, consuming enough water, and getting regular exercise. [13]

Obesity during pregnancy

Maternal obesity is a rising epidemic among pregnant women, that is detrimental to both the health of the baby and the mother. Obesity leads pregnant women to develop gestational diabetes and preeclampsia, and increase the risk of stillbirth and numerous congenital anomalies. Beyond the immediate risks during pregnancy, the obesity of the mother tends to create a predisposition for the baby to have the inclination to develop conditions like heart disease and diabetes. [14] During pregnancy, the rate at which nutrition is absorbed and conveyed to the fetus affects its physiology and metabolic regularity. Nutrition available in either abundance, or scarcity, both affect the overall outcome of the fetus, thus creating a precursor for future health developments. Typical treatment includes monitored consumption of food, as well as moderate exercise.

Historically significant ailments in the 1900s

Puerperal sepsis

Puerperal Sepsis is a bacterial infection that affects the genital tract, commonly occurring after the birth of a baby. The symptoms typically appear one day after pregnancy, however symptoms may appear earlier if the woman has had prolonged damage to the membranes in the vaginal tract. This was a leading factor in maternal mortality, as 80%-90% of women in some hospitals did not survive after receiving their diagnosis due to the rapidly spreading nature of the infection. Malnourished women, or with women with anaemia were susceptible to the infection. Some common symptoms included, but were not limited to: fever (temperature of 38 °C or more), chills and general malaise, lower abdominal pain, tender uterus, sub involution of the uterus purulent, and foul-smelling lochia. [15]

Special cases

Pregnancy and HIV

HIV positive women who become pregnant require special types of treatment in order to prevent transmission from mother to fetus. Antiretrovirals are medications that reduce the viral load of the HIV virus in the mother's fluids and blood. Reduction of the viral load reduces the chance of the baby to become infected. [16]

Ethics

Many ethical issues arise around whether the mothers right to autonomy may have adverse effects on the fetus. These types of situations have been described as maternal autonomy vs. fetal rights. [17] In the case of Angela Carter, In re A.C., a court order to perform an emergency cesarean section resulted in the death of the severely premature fetus and the terminally ill mother. In addition, obstetricians and pediatricians face challenges when a pregnant HIV positive woman refuses treatment to prevent transmission from mother to baby. In these cases, mothers have the right to refuse treatments during pregnancy, but may subsequently face custody battles from the government to prevent the transmission of HIV via breastfeeding. [18]

Another important field of discussion is what types of clinical trials are ethically appropriate for pregnant mothers. When a drug designed to benefit the health of the mother is being tested, the potential benefits of the drug may only be explored if the risk to the fetus is minimal. However, the concern is how severe must a health condition must be to justify exposing the fetus to any sort of risk. Clinical trials on pregnant women are forbidden if the drug is not designed for the benefit of the mother or fetus. [19]

Related Research Articles

Obstetrics is the field of study concentrated on pregnancy, childbirth and the postpartum period. As a medical specialty, obstetrics is combined with gynecology under the discipline known as obstetrics and gynecology (OB/GYN), which is a surgical field.

Maternal death Aspect of human reproduction and medicine

Maternal death or maternal mortality is defined in slightly different ways by several different health organizations. The World Health Organization (WHO) defines maternal death as the death of a pregnant woman due to complications related to pregnancy, underlying conditions worsened by the pregnancy or management of these conditions. This can occur either while she is pregnant or within six weeks of resolution of the pregnancy. The CDC definition of pregnancy-related deaths extends the period of consideration to include one year from the resolution of the pregnancy. Pregnancy associated death, as defined by the American College of Obstetricians and Gynecologists (ACOG), are all deaths occurring within one year of a pregnancy resolution. Identification of pregnancy associated deaths is important for deciding whether or not the pregnancy was a direct or indirect contributing cause of the death.

Pre-eclampsia Hypertension occurring during pregnancy

Pre-eclampsia is a disorder of pregnancy characterized by the onset of high blood pressure and often a significant amount of protein in the urine. When it arises, the condition begins after 20 weeks of pregnancy. In severe cases of the disease there may be red blood cell breakdown, a low blood platelet count, impaired liver function, kidney dysfunction, swelling, shortness of breath due to fluid in the lungs, or visual disturbances. Pre-eclampsia increases the risk of undesirable outcomes for both the mother and the fetus. If left untreated, it may result in seizures at which point it is known as eclampsia.

Fetal distress, also known as non-reassuring fetal status, is a condition during pregnancy or labor in which the fetus shows signs of inadequate oxygenation. Due to its imprecision, the term "fetal distress" has fallen out of use in American obstetrics. The term "non-reassuring fetal status" has largely replaced it. It is characterized by changes in fetal movement, growth, heart rate, and presence of meconium stained fluid.

Gestational diabetes Medical condition

Gestational diabetes is a condition in which a woman without diabetes develops high blood sugar levels during pregnancy. Gestational diabetes generally results in few symptoms; however, it does increase the risk of pre-eclampsia, depression, and requiring a Caesarean section. Babies born to mothers with poorly treated gestational diabetes are at increased risk of being too large, having low blood sugar after birth, and jaundice. If untreated, it can also result in a stillbirth. Long term, children are at higher risk of being overweight and developing type 2 diabetes.

Gestational hypertension Medical condition

Gestational hypertension or pregnancy-induced hypertension (PIH) is the development of new hypertension in a pregnant woman after 20 weeks' gestation without the presence of protein in the urine or other signs of pre-eclampsia. Gestational hypertension is defined as having a blood pressure greater than 140/90 on two occasions at least 6 hours apart.

Gestational age is a measure of the age of a pregnancy which is taken from the beginning of the woman's last menstrual period (LMP), or the corresponding age of the gestation as estimated by a more accurate method if available. Such methods include adding 14 days to a known duration since fertilization, or by obstetric ultrasonography. The popularity of using such a definition of gestational age is that menstrual periods are essentially always noticed, while there is usually a lack of a convenient way to discern when fertilization occurred.

Pregnancy Time of offspring development in mothers body

Pregnancy is the time during which one or more offspring develops (gestates) inside a woman's womb. A multiple pregnancy involves more than one offspring, such as with twins. Pregnancy usually occurs by sexual intercourse, but can also occur through assisted reproductive technology procedures. A pregnancy may end in a live birth, a spontaneous miscarriage, an induced abortion, or a stillbirth. Childbirth typically occurs around 40 weeks from the start of the last menstrual period (LMP), a span known as the gestational age. This is just over nine months. Counting by fertilization age, the length is about 38 weeks. Pregnancy has also been defined as "the presence of an implanted human embryo or fetus in the uterus"; implantation occurs on average 8–9 days after fertilization. An embryo is the term for the developing offspring during the first seven weeks following implantation, after which the term fetus is used until birth. Signs and symptoms of early pregnancy may include missed periods, tender breasts, morning sickness, hunger, and frequent urination. Pregnancy may be confirmed with a pregnancy test. Methods of birth control—or, more accurately, contraception—are used to avoid pregnancy.

Large for gestational age Medical condition

Large for gestational age (LGA) is a term used to describe infants that are born with an abnormally high weight, specifically in the 90th percentile or above, compared to other babies of the same developmental age. Macrosomia is a similar term that describes excessive birth weight, but refers to an absolute measurement, regardless of gestational age. Typically the threshold for diagnosing macrosomia is a body weight of between 4,000 and 4,500 grams, or more, measured at birth, but there are difficulties reaching a universal agreement of this definition.

Complications of pregnancy Medical condition

Complications of pregnancy are health problems that are related to pregnancy. Complications that occur primarily during childbirth are termed obstetric labor complications, and problems that occur primarily after childbirth are termed puerperal disorders. Severe complications of pregnancy, childbirth, and the puerperium are present in 1.6% of mothers in the US, and in 1.5% of mothers in Canada. In the immediate postpartum period (puerperium), 87% to 94% of women report at least one health problem. Long-term health problems are reported by 31% of women.

Diabetes and pregnancy Effects of pre-existing diabetes upon pregnancy

For pregnant women with diabetes, some particular challenges exist for both mother and child. If the pregnant woman has diabetes as a pre-existing disorder, it can cause early labor, birth defects, and larger than average infants. Therefore, experts advise diabetics to maintain blood sugar level close to normal range about 3 months before planning for pregnancy.

Intrauterine hypoxia Medical condition

Intrauterine hypoxia occurs when the fetus is deprived of an adequate supply of oxygen. It may be due to a variety of reasons such as prolapse or occlusion of the umbilical cord, placental infarction, maternal diabetes and maternal smoking. Intrauterine growth restriction may cause or be the result of hypoxia. Intrauterine hypoxia can cause cellular damage that occurs within the central nervous system. This results in an increased mortality rate, including an increased risk of sudden infant death syndrome (SIDS). Oxygen deprivation in the fetus and neonate have been implicated as either a primary or as a contributing risk factor in numerous neurological and neuropsychiatric disorders such as epilepsy, attention deficit hyperactivity disorder, eating disorders and cerebral palsy.

Maternal health is the health of women during pregnancy, childbirth, and the postpartum period. In most cases, it encompasses the health care dimensions of family planning, preconception, prenatal, and postnatal care in order to ensure a positive and fulfilling experience. In other cases, maternal health can reduce maternal morbidity and mortality. Maternal health revolves around the health and wellness of women, particularly when they are pregnant, at the time they give birth, and during child-raising. WHO has indicated that even though motherhood has been considered as a fulfilling natural experience that is emotional to the mother, a high percentage of women develop health problems and sometimes even die. Because of this, there is a need to invest in the health of women. The investment can be achieved in different ways, among the main ones being subsidizing the healthcare cost, education on maternal health, encouraging effective family planning, and ensuring progressive check up on the health of women with children. Maternal mortality particularly affects women of color and women living in low and lower-middle income countries.

Maternal–fetal medicine Branch of medicine

Maternal–fetal medicine (MFM), also known as perinatology, is a branch of medicine that focuses on managing health concerns of the mother and fetus prior to, during, and shortly after pregnancy.

The following outline is provided as an overview of and topical guide to obstetrics:

Prenatal nutrition

Prenatal nutrition addresses nutrient recommendations before and during pregnancy. Nutrition and weight management before and during pregnancy has a profound effect on the development of infants. This is a rather critical time for healthy development since infants rely heavily on maternal stores and nutrient for optimal growth and health outcome later in life.

Prenatal care in the United States is a health care preventive care protocol recommended to women with the goal to provide regular check-ups that allow obstetricians-gynecologists or midwives to detect, treat and prevent potential health problems throughout the course of pregnancy while promoting healthy lifestyles that benefit both mother and child. Patients are encouraged to attend monthly checkups during the first two trimesters and in the third trimester gradually increasing to weekly visits. Women who suspect they are pregnant can schedule pregnancy tests prior to 9 weeks gestation. Once pregnancy is confirmed an initial appointment is scheduled after 8 weeks gestation. Subsequent appointments consist of various tests ranging from blood pressure to glucose levels to check on the health of the mother and fetus. If not, appropriate treatment will then be provided to hinder any further complications.

High-risk pregnancy Medical condition

A high-risk pregnancy is one where the mother or the fetus has an increased risk of adverse outcomes compared to uncomplicated pregnancies. No concrete guidelines currently exist for distinguishing “high-risk” pregnancies from “low-risk” pregnancies, however there are certain studied conditions that have been shown to put the mother or fetus at a higher risk of poor outcomes. These conditions can be classified into three main categories: health problems in the mother that occur before she becomes pregnant, health problems in the mother that occur during pregnancy, and certain health conditions with the fetus.

Hypertensive disease of pregnancy, also known as maternal hypertensive disorder, is a group of high blood pressure disorders that include preeclampsia, preeclampsia superimposed on chronic hypertension, gestational hypertension, and chronic hypertension.

Maternal health outcomes differ significantly between racial groups within the United States. The American College of Obstetricians and Gynecologists describes these disparities in obstetric outcomes as "prevalent and persistent." Black, indigenous, and people of color are disproportionately affected by many of the maternal health outcomes listed as national objectives in the U.S. Department of Health and Human Services's national health objectives program, Healthy People 2030. The American Public Health Association considers maternal mortality to be a human rights issue, also noting the disparate rates of Black maternal death. Race affects maternal health throughout the pregnancy continuum, beginning prior to conception and continuing through pregnancy (antepartum), during labor and childbirth (intrapartum), and after birth (postpartum).

References

  1. 1 2 "What is Obstetric Medicine?". Macdonald Obstetric Medicine Society (UK). Retrieved 2014-01-22.
  2. ↑ Drife, J. (2002-05-01). "The start of life: a history of obstetrics". Postgraduate Medical Journal. 78 (919): 311–315. doi:10.1136/pmj.78.919.311. ISSN   1469-0756. PMC   1742346 . PMID   12151591.
  3. 1 2 3 "Obstetrics and gynecology | medicine". Encyclopedia Britannica. Retrieved 2018-11-06.
  4. ↑ Drife, J. (2002-05-01). "The start of life: a history of obstetrics". Postgraduate Medical Journal. 78 (919): 311–315. doi:10.1136/pmj.78.919.311. ISSN   0032-5473. PMC   1742346 . PMID   12151591.
  5. 1 2 Loudon, Irvine (2008-11-01). "General practitioners and obstetrics: a brief history". Journal of the Royal Society of Medicine. 101 (11): 531–535. doi:10.1258/jrsm.2008.080264. ISSN   0141-0768. PMC   2586862 . PMID   19029353.
  6. ↑ "The Midwives Act 1902: an historical landmark | RCM". www.rcm.org.uk. Retrieved 2018-12-10.
  7. ↑ Firoz, Tabassum; Ateka-Barrutia, Oier; Rojas-Suarez, Jose Antonio; Wijeyaratne, Chandrika; Castillo, Eliana; Lombaard, Hennie; Magee, Laura A (September 2015). "Global obstetric medicine: Collaborating towards global progress in maternal health". Obstetric Medicine. 8 (3): 138–145. doi:10.1177/1753495X15595308. ISSN   1753-495X. PMC   4935022 . PMID   27512469.
  8. 1 2 Care, Institute of Medicine (US) Committee to Study Outreach for Prenatal; Brown, Sara S. (1988). Barriers to the Use of Prenatal Care. National Academies Press (US).
  9. ↑ Philipp, Elliot E (July 2001). "The Obstetrician's Armamentarium: Historical Obstetric Instruments and Their Inventors". Journal of the Royal Society of Medicine. 94 (7): 362–363. doi:10.1177/014107680109400716. ISSN   0141-0768. PMC   1281608 .
  10. ↑ "Pregnancy complications | womenshealth.gov". womenshealth.gov. 2016-12-14. Retrieved 2018-11-03.
  11. ↑ "What is Gestational Diabetes?". American Diabetes Association. Retrieved 2018-11-03.
  12. ↑ "How to Treat Gestational Diabetes". American Diabetes Association. Retrieved 2018-11-03.
  13. ↑ "Gestational Hypertension: Pregnancy Induced Hypertension". American Pregnancy Association. 2012-04-26. Retrieved 2018-11-03.
  14. ↑ Leddy, Meaghan A; Power, Michael L; Schulkin, Jay (2008). "The Impact of Maternal Obesity on Maternal and Fetal Health". Reviews in Obstetrics and Gynecology. 1 (4): 170–178. ISSN   1941-2797. PMC   2621047 . PMID   19173021.
  15. ↑ "WHO | Managing puerperal sepsis". WHO. Archived from the original on May 7, 2013. Retrieved 2018-12-10.
  16. ↑ "HIV Medicines During Pregnancy and Childbirth Understanding HIV/AIDS". AIDSinfo. Retrieved 2018-12-10.
  17. ↑ Isaacs, D. (January 2003). "Moral status of the fetus: Fetal rights or maternal autonomy?". Journal of Paediatrics and Child Health. 39 (1): 58–59. doi: 10.1046/j.1440-1754.2003.00088.x . ISSN   1034-4810. PMID   12542815.
  18. ↑ "HIV and Pregnancy: Medical and Legal Considerations for Women and Their Advocates, Center for HIV Law and Policy". The Center for HIV Law and Policy. 2009. Retrieved 2018-12-10.
  19. ↑ Federman, Daniel; Faden, Ruth; Mastroianni, Anna C.; Studies, Institute of Medicine (US) Committee on the Ethical and Legal Issues Relating to the Inclusion of Women in Clinical (1999). Ethical Issues Related to the Inclusion of Pregnant Women in Clinical Trials (I). US: National Academies Press.
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