Obstetrics

Last updated
Obstetrician
Occupation
Names
  • Physician
  • Surgeon
Occupation type
 Specialty
Activity sectors
 Medicine, surgery
Description
Education required
Fields of
employment
 Hospitals, clinics

Obstetrics is the field of study concentrated on pregnancy, childbirth and the postpartum period. [1] As a medical specialty, obstetrics is combined with gynecology under the discipline known as obstetrics and gynecology (OB/GYN), which is a surgical field. [2]

Contents

Main areas

Prenatal care

Prenatal care is important in screening for various complications of pregnancy. [3] This includes routine office visits with physical exams and routine lab tests along with telehealth care for people with low-risk pregnancies: [4]

First trimester

Routine tests in the first trimester of pregnancy generally include:

Genetic screening for Down syndrome (trisomy 21) and Edwards syndrome (trisomy 18), the national standard in the United States, is rapidly evolving away from the AFP-quad screen, done typically in the second trimester at 16–18 weeks. [11] 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 (thicker nuchal skin correlates with higher risk of Down syndrome being present) and two chemicals (analytes), pregnancy-associated plasma protein A and human chorionic gonadotropin (pregnancy hormone level itself [12] ). It gives an accurate risk profile very early. A second blood screen at 15 to 20 weeks refines the risk more accurately. [13] 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. [14] [15] [16]

Down syndrome karyotype Down Syndrome karyotype.png
Down syndrome karyotype

Second trimester

  • MSAFP/quad. screen (four simultaneous blood tests) (maternal serum AFP, inhibin A, estriol, and βHCG) – elevations, low numbers or odd patterns correlate with neural tube defect risk and increased risks of trisomy 18 or trisomy 21 [17]
  • Ultrasound either abdominal or transvaginal to assess cervix, placenta, fluid and baby [18]
  • Amniocentesis is the national standard for women over 35 or who reach 35 by mid pregnancy or who are at increased risk by family history or prior birth history. [16]

Third trimester

  • Hematocrit (if low, the mother receives iron supplements) [19]
  • Group B Streptococcus screen. If positive, the woman receives IV penicillin or ampicillin while in labor—or, if she is allergic to penicillin, an alternative therapy, such as IV clindamycin or IV vancomycin. [16]
  • 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. [20]

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. [21]

The result of an ultrasonography: a black and white image that shows a clear view of the interior abdomen Ultrasonography of abdominal pregnancy.jpg
The result of an ultrasonography: a black and white image that shows a clear view of the interior abdomen

Fetal assessments

A dating scan at 12 weeks Scan12weeks.jpg
A dating scan at 12 weeks

Obstetric ultrasonography is routinely used for dating the gestational age of a pregnancy from the size of the fetus, determine the number of fetuses and placentae, evaluate for an ectopic pregnancy and first trimester bleeding, the most accurate dating being in first trimester before the growth of the foetus has been significantly influenced by other factors. [22] Ultrasound is also used for detecting congenital anomalies (or other foetal anomalies) and determining the biophysical profiles (BPP), which are generally easier to detect in the second trimester when the foetal structures are larger and more developed. [23]

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 foetus. [24] No effects of magnetic resonance imaging (MRI) on the foetus have been demonstrated, [25] 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. [26]

The safety of frequent ultrasound scanning has not been confirmed. Despite this, increasing numbers of women are choosing to have additional scans for no medical purpose, such as gender scans, 3D and 4D scans. [27] A normal gestation would reveal a gestational sac, yolk sac, and fetal pole. [28]

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. [29]

Other tools used for assessment include:

Diseases in pregnancy

A pregnant woman may have a pre-existing disease, that may become worse or become a risk to the pregnancy, or to postnatal development of the offspring [35]

Induction and labour

Induction is a method of artificially or prematurely stimulating labour in a woman. [47] Reasons to induce can include pre-eclampsia, foetal distress, placental malfunction, intrauterine growth retardation and failure to progress through labour increasing the risk of infection and foetal distresses. [48]

Induction may be achieved via several methods:

During labour, the obstetrician carries out the following tasks:

Complications and emergencies

The main emergencies include:

Postpartum period

The World Health Organization makes a distinction between the use of postpartum care when it concerns the care of the mother after giving birth, and postnatal care when the care of the newborn is concerned. [73] Postpartum care is provided to the mother following childbirth.

A woman in the Western world who gives birth 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 later, but usually averages a stay of one or two days; the average postnatal stay following delivery by caesarean section is three to four days. [74]

During this time the mother is monitored for bleeding, bowel and bladder function, and baby care. The infant's health is also monitored. [75]

Veterinary obstetrics

History

Two midwives assisting a woman in labour on a birthing chair in the 16th century, from a work by Eucharius Rosslin Eucharius Rosslin Rosgarten Childbirth.jpg
Two midwives assisting a woman in labour on a birthing 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. [76] The expectant mother would invite close female friends and family members to her home to keep her company during childbirth. [77] : 96–98  Skilled midwives managed all aspects of the labour and delivery. [78] The presence of physicians and surgeons was very rare and only occurred if a serious complication had taken place and the midwife had exhausted all measures at her disposal. [79] Calling a surgeon was very much a last resort and having men deliver women in this era was seen as offending female modesty. [80] : 1050–1051  [81]

Before the 18th century

Prior to the 18th and 19th centuries, midwifery was well established but obstetrics was not recognized as a specific medical specialty. However, the subject matter and interest in the female reproductive system and sexual practice can be traced back to Ancient Egypt [82] : 122  and Ancient Greece. [83] : 11  Soranus of Ephesus sometimes is called the most important figure in ancient gynecology. [79] Living in the late first century AD and early second century, he studied anatomy and had opinions and techniques on abortion, contraception – most notably coitus interruptus  – and birth complications. After his death, techniques and works of gynecology declined; very little of his works were recorded and survived to the late 18th century when gynecology and obstetrics reemerged as a medical specialism. [82] : 123 

18th century

The 18th century marked the beginning of many advances in European midwifery, based on better knowledge of the physiology of pregnancy and labour. [84] By the end of the century, medical professionals began to understand the anatomy of the uterus and the physiological changes that take place during labour. [85] The introduction of forceps in childbirth also took place at this time. All these medical advances in obstetrics were a lever for the introduction of men into an arena previously managed and run by women – midwifery. [80] : 1051–1052 

The addition of the male-midwife (or man-midwife) is historically a significant change to the profession of obstetrics. [86] 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. [87] In France these male-midwives were referred to as accoucheurs, a title later used all over Europe. The founding of lying-in hospitals also contributed to the medicalization and male-dominance of obstetrics. [88] These early maternity hospitals were establishments where women would come to have their babies delivered, as opposed to the practice since time immemorial of the midwife attending the home of the woman in labour. [89] This institution provided male-midwives with endless patients to practice their techniques on and was a way for these men to demonstrate their knowledge. [90]

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 male-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. [80] : 1050–1051 

19th century

18th-century physicians expected that obstetrics would continue to grow, but the opposite happened. Obstetrics entered a stage of stagnation in the 19th century, which lasted until about the 1880s. [77] : 96–98  The central explanation for the lack of advancement during this time was the rejection of obstetrics by the medical community. [91] The 19th century marked an era of medical reform in Europe and increased regulation over the profession. Major European institutions such as The College of Physicians and Surgeons[ where? ] 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. [92] 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. [80] : 1053–1055 

By the late 19th century, the foundation of modern-day obstetrics and midwifery began developing. Delivery of babies by doctors became popular and readily accepted, but midwives continued to play a role in childbirth. [87] Midwifery also changed during this era due to increased regulation and the eventual need for midwives to become certified. [93] 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. [94]

As midwifery began to develop, so did the profession of obstetrics near the end of the century. [95] Childbirth was no longer unjustifiably despised by the medical community as it once had been at the beginning of the century. But obstetrics was underdeveloped compared to other medical specialities. 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 anaesthesia, which paved the way for the mainstream introduction and later success of the Caesarean section. [94] [96]

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, then known as childbed fever. In the 1800s 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%. [97] So it was concluded that it was physicians who had been spreading disease from one labouring 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.[ citation needed ]

History of obstetrics in America

The development of obstetrics as a practice for accredited doctors happened at the turn of the 18th century and thus was very differently developed in Europe and in the Americas due to the independence of many countries in the Americas from European powers. "Unlike in Europe and the British Isles, where midwifery laws were national, in America, midwifery laws were local and varied widely". [98]

Gynaecology and Obstetrics gained attention in the American medical field at the end of the nineteenth century through the development of such procedures as the ovariotomy. [99] These procedures then were shared with European surgeons who replicated the surgeries. This was a period when antiseptic, aseptic or anaesthetic measures were just being introduced to surgical and observational procedures and without these procedures surgeries were dangerous and often fatal. [100] Following are two surgeons noted for their contributions to these fields include Ephraim McDowell and J. Marion Sims. [101]

Ephraim McDowell developed a surgical practice in 1795 and performed the first ovariotomy in 1809 on a 47-year-old widow who then lived on for 31 more years. [102] He had attempted to share this with John Bell whom he had practiced under who had retired to Italy. Bell was said to have died without seeing the document but it was published by an associate in Extractions of Diseased Ovaria in 1825. [103] By the mid-century the surgery was both successfully and unsuccessfully being performed. Pennsylvanian surgeons the Attlee brothers made this procedure very routine for a total of 465 surgeries – John Attlee performed 64 successfully of 78 while his brother William reported 387 – between the years of 1843 and 1883. [104] By the middle of the nineteenth century this procedure was successfully performed in Europe by English surgeons Sir Spencer Wells and Charles Clay as well as French surgeons Eugène Koeberlé, Auguste Nélaton and Jules Péan. [82] : 125 

J. Marion Sims was the surgeon responsible for being the first treating a vesicovaginal fistula [82] : 125  – a condition linked to many caused mainly by prolonged pressing of the foetus against the pelvis or other causes such as rape, hysterectomy, or other operations – and also having been doctor to many European royals and the 20th President of the United States James A. Garfield after he had been shot. Sims does have a controversial medical past. Under the beliefs at the time about pain and the prejudice towards African people, he had practiced his surgical skills and developed skills on slaves. [105] These women were the first patients of modern gynecology. One of the women he operated on was named Anarcha Westcott, the woman he first treated for a fistula. [105]

Historical role of gender

Women and men inhabited very different roles in natal care up to the 18th century. [106] The role of a physician was exclusively held by men who went to university, an overly male institution, who would theorize anatomy and the process of reproduction based on theological teaching and philosophy. Many beliefs about the female body and menstruation in the 17th and 18th centuries were inaccurate; clearly resulting from the lack of literature about the practice. [82] : 123–125  Many of the theories of what caused menstruation prevailed from Hippocratic philosophy. [83] : 16  Midwives, meaning "with woman", were those who assisted in the birth and care of both born and unborn children, a position historically held mainly by women. [107]

During the birth of a child, men were rarely present. Women from the neighbourhood or family would join in on the process of birth and assist in many different ways. [108] The one position where men would help with the birth of a child would be in the sitting position, usually when performed on the side of a bed to support the mother. [77] : 130 

Men were introduced into the field of obstetrics in the nineteenth century and resulted in a change of the focus of this profession. [109] Gynaecology directly resulted as a new and separate field of study from obstetrics and focused on the curing of illness and indispositions of female sexual organs. [110] This had some relevance to some conditions as menopause, uterine and cervical problems, and childbirth could leave the mother in need of extensive surgery to repair tissue. [111] But, there was also a large blame of the uterus for completely unrelated conditions. This led to many social consequences of the nineteenth century. [82] : 123–125 

See also

Related Research Articles

<span class="mw-page-title-main">Midwifery</span> Pregnancy and childbirth-related profession

Midwifery is the health science and health profession that deals with pregnancy, childbirth, and the postpartum period, in addition to the sexual and reproductive health of women throughout their lives. In many countries, midwifery is a medical profession. A professional in midwifery is known as a midwife.

<span class="mw-page-title-main">Childbirth</span> Conclusion of the human pregnancy with the expulsion of a fetus from mothers womb

Childbirth, also known as labour, parturition and delivery, is the completion of pregnancy where one or more babies exits the internal environment of the mother via vaginal delivery or caesarean section. In 2019, there were about 140.11 million human births globally. In the developed countries, most deliveries occur in hospitals, while in the developing countries most are home births.

<span class="mw-page-title-main">Miscarriage</span> Natural death and expulsion of an embryo or fetus before its independent survival

Miscarriage, also known in medical terms as a spontaneous abortion, is the death and expulsion of an embryo or fetus before it can survive independently. The term miscarriage is sometimes used to refer to all forms of pregnancy loss and pregnancy with abortive outcomes before 20 weeks of gestation.

<span class="mw-page-title-main">Amniocentesis</span> Sampling of amniotic fluid done mainly to detect fetal chromosomal abnormalities

Amniocentesis is a medical procedure used primarily in the prenatal diagnosis of genetic conditions. It has other uses such as in the assessment of infection and fetal lung maturity. Prenatal diagnostic testing, which includes amniocentesis, is necessary to conclusively diagnose the majority of genetic disorders, with amniocentesis being the gold-standard procedure after 15 weeks' gestation.

<span class="mw-page-title-main">Obstetric ultrasonography</span> Use of medical ultrasonography in pregnancy

Obstetric ultrasonography, or prenatal ultrasound, is the use of medical ultrasonography in pregnancy, in which sound waves are used to create real-time visual images of the developing embryo or fetus in the uterus (womb). The procedure is a standard part of prenatal care in many countries, as it can provide a variety of information about the health of the mother, the timing and progress of the pregnancy, and the health and development of the embryo or fetus.

<span class="mw-page-title-main">Prenatal testing</span> Testing for diseases or conditions in a fetus

Prenatal testing is a tool that can be used to detect some birth defects at various stages prior to birth. Prenatal testing consists of prenatal screening and prenatal diagnosis, which are aspects of prenatal care that focus on detecting problems with the pregnancy as early as possible. These may be anatomic and physiologic problems with the health of the zygote, embryo, or fetus, either before gestation even starts or as early in gestation as practicable. Screening can detect problems such as neural tube defects, chromosome abnormalities, and gene mutations that would lead to genetic disorders and birth defects, such as spina bifida, cleft palate, Down syndrome, trisomy 18, Tay–Sachs disease, sickle cell anemia, thalassemia, cystic fibrosis, muscular dystrophy, and fragile X syndrome. Some tests are designed to discover problems which primarily affect the health of the mother, such as PAPP-A to detect pre-eclampsia or glucose tolerance tests to diagnose gestational diabetes. Screening can also detect anatomical defects such as hydrocephalus, anencephaly, heart defects, and amniotic band syndrome.

<span class="mw-page-title-main">Placental abruption</span> Medical condition

Placental abruption is when the placenta separates early from the uterus, in other words separates before childbirth. It occurs most commonly around 25 weeks of pregnancy. Symptoms may include vaginal bleeding, lower abdominal pain, and dangerously low blood pressure. Complications for the mother can include disseminated intravascular coagulopathy and kidney failure. Complications for the baby can include fetal distress, low birthweight, preterm delivery, and stillbirth.

In obstetrics, gestational age is a measure of the age of a pregnancy 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 this measure of pregnancy is largely due to convenience: menstruation is usually noticed, while there is generally no convenient way to discern when fertilization or implantation occurred.

<span class="mw-page-title-main">Pregnancy</span> Time of offspring development in mothers body

Pregnancy is the time during which one or more offspring develops (gestates) inside a woman's uterus (womb). A multiple pregnancy involves more than one offspring, such as with twins.

<span class="mw-page-title-main">Large for gestational age</span> 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 between 4,000 and 4,500 grams, or more, measured at birth, but there are difficulties reaching a universal agreement of this definition.

<span class="mw-page-title-main">Complications of pregnancy</span> Medical condition

Complications of pregnancy are health problems that are related to, or arise during pregnancy. Complications that occur primarily during childbirth are termed obstetric labor complications, and problems that occur primarily after childbirth are termed puerperal disorders. While some complications improve or are fully resolved after pregnancy, some may lead to lasting effects, morbidity, or in the most severe cases, maternal or fetal mortality.

<span class="mw-page-title-main">Nuchal scan</span> Routine ultrasound done between 11 and 14 weeks pregnancy

A nuchal scan or nuchal translucency (NT) scan/procedure is a sonographic prenatal screening scan (ultrasound) to detect chromosomal abnormalities in a fetus, though altered extracellular matrix composition and limited lymphatic drainage can also be detected.

<span class="mw-page-title-main">Velamentous cord insertion</span> Velamentous placenta

Velamentous cord insertion is a complication of pregnancy where the umbilical cord is inserted in the fetal membranes. It is a major cause of antepartum hemorrhage that leads to loss of fetal blood and associated with high perinatal mortality. In normal pregnancies, the umbilical cord inserts into the middle of the placental mass and is completely encased by the amniotic sac. The vessels are hence normally protected by Wharton's jelly, which prevents rupture during pregnancy and labor. In velamentous cord insertion, the vessels of the umbilical cord are improperly inserted in the chorioamniotic membrane, and hence the vessels traverse between the amnion and the chorion towards the placenta. Without Wharton's jelly protecting the vessels, the exposed vessels are susceptible to compression and rupture.

<span class="mw-page-title-main">Placental disease</span> Medical condition

A placental disease is any disease, disorder, or pathology of the placenta.

Amnioinfusion is a method in which isotonic fluid is instilled into the uterine cavity.

<span class="mw-page-title-main">High-risk pregnancy</span> Medical condition

A high-risk pregnancy is a pregnancy 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.

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 humans. 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.

Early pregnancy bleeding is vaginal bleeding before 14 weeks of gestational age. If the bleeding is significant, hemorrhagic shock may occur. Concern for shock is increased in those who have loss of consciousness, chest pain, shortness of breath, or shoulder pain.

The anomaly scan, also sometimes called the anatomy scan, 20-week ultrasound, or level 2 ultrasound, evaluates anatomic structures of the fetus, placenta, and maternal pelvic organs. This scan is an important and common component of routine prenatal care. The function of the ultrasound is to measure the fetus so that growth abnormalities can be recognized quickly later in pregnancy, to assess for congenital malformations and multiple pregnancies, and to plan method of delivery.

<span class="mw-page-title-main">Pregnancy Outcome Prediction study</span>

The Pregnancy Outcome Prediction (POP) Study is a prospective cohort study of 4,512 women who have never given birth, recruited at the Rosie Hospital between January 2008 and July 2012.

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