Obstetrics and gynecology

Summary

Obstetrics and gynecology are medical specialties focused on women's health care. Obstetrics entails the care of a woman and her developing fetus from conception through delivery and following delivery (postpartum care). Gynecology encompasses the evaluation and treatment (both medical and surgical) of the female reproductive system (uterus, Fallopian tubes, ovaries, vagina, and external genitalia).

Definition and Basic Principles

Obstetrics and gynecology are medical specialties limited to women's health care. Many obstetrician-gynecologists are generalists and provide obstetrical and gynecologic care. However, some limit their practice to obstetrics or gynecology. Some focus on problems of menopause, and some focus on gynecologic care of children and adolescents. Some obstetrician-gynecologists receive additional training in a specific area of the field. The following subspecialties are recognized: gynecologic oncology, the medical and surgical treatment of cancers of the female genital tract (the ovaries, uterus, cervix, vagina, and external genitalia); reproductive endocrinology, the treatment of infertility in women; maternal-fetal medicine, the treatment of high-risk pregnancies; and urogynecology, the medical and surgical treatment of problems of the female urinary tract. Generalists often refer their more complicated and challenging cases to these subspecialists and, in many cases, comanage the patients' care.

As with other medical specialties, obstetrics and gynecology have become more sophisticated and technologically advanced. For example, infertility specialists can help women with certain conditions have children. However, fifty years ago, women with those same conditions would not have been able to give birth. Endoscopy, the visualization of internal structures with a small viewing device, has enabled physicians to better understand their patients' conditions and provide appropriate treatment. Although a breast examination is a common part of the gynecologic exam, treatment of breast disease is usually referred to surgeons who specialize in breast disease.

Background and History

In Western civilization, female midwives first practiced obstetrics in the seventeenth century. In colonial America, about one in eight women would die in childbirth, and of every ten infants born, between one and three would die before reaching the age of five. Midwives would call male surgeons to the birthing room if they determined that the infant had died while in the womb. The surgeon's task was to use instruments to reduce the size of the baby's skull and extract the body. Toward the end of the seventeenth century, doctors began to perform cesarean sections. In the eighteenth century, forceps were developed to assist in the delivery process. In the nineteenth century, painkillers began to be used during childbirth. In the 1940s and 1950s, the use of anesthesia increased to the point that women were often rendered semiconscious during the labor process. This excessive use of sedation produced a backlash, and in the 1970s, natural childbirth became popular. Advocates argued that childbirth was a natural process, not a disease needing treatment. Many women began to use a variety of techniques to avoid using medication during labor and sought alternatives to hospital births, including using midwives rather than obstetricians.

In the nineteenth century, the direct viewing of a woman's genitals by a physician, who was nearly always male, was regarded as immoral and immodest, and physicians had to rely on palpitation of the area. This made it difficult to diagnose and treat gynecologic problems. Gynecologic surgery, as well as surgery in general, did not develop until after the introduction of anesthesia in the nineteenth century. In the mid-1800s, J. Marion Sims developed a surgical treatment for vesicovaginal fistula, a complication of childbirth that causes urine leakage and discomfort, and he became known as the father of gynecology. Because Sims worked on enslaved women, he was able to observe their genitals directly. In 1869, Commander D. C. Pantaleoni performed the first operative hysteroscopy, paving the way for modern endoscopy (hysteroscopy and laparoscopy). In 1978, English gynecologist Patrick Steptoe announced the birth of a child through in vitro fertilization.

How It Works

Some family practice doctors, typically in rural areas with a low population density, offer obstetrical services, but in urban areas, obstetricians generally handle pregnancy care. An obstetrician cares for a woman and her fetus/infant throughout pregnancy (antepartum), during labor (intrapartum), and following delivery (postpartum). An obstetrician (or obstetrical group) may also be associated with nurse practitioners and sometimes nurse midwives.

Obstetricians confirm a woman's pregnancy and then set up a schedule of visits, ranging from once a week to once a month, depending on the stage of pregnancy and whether complications are present. During a prenatal visit, the obstetrician listens for fetal heart tones, records the woman's weight and blood pressure, and checks her urine for abnormalities, such as the presence of protein or sugar. Protein in the urine, accompanied by elevated blood pressure and increased reflexes, may indicate that the woman has toxemia (preeclampsia), which is life-threatening to both the woman and her fetus. The presence of sugar may indicate that the woman has developed gestational diabetes, which poses a threat to her fetus. Both conditions are treatable but require extra monitoring of the woman and fetus. Blood is drawn to check for anemia, screen for congenital disabilities, and determine the blood type and Rh, or rhesus, factor. If a woman is Rh negative and her fetus is Rh positive, the risk of an immune reaction is present. This incompatibility may not cause problems during the woman's first pregnancy. However, if a subsequent fetus is Rh positive, it could develop Rh disease, a life-threatening condition that could cause anemia or other serious problems. An obstetrician can also provide invaluable information on many aspects of pregnancy, such as nutrition, foods, or medication to avoid, and exercise guidelines.

Some family practitioners and internists, especially those in rural areas, offer gynecologic services, although, in urban areas, women often visit gynecologists for this care. Many women turn to gynecologists for problems with their reproductive system and other medical conditions. Thus, their gynecologists function as primary care or family physicians. Many gynecologists also function as obstetricians and will continue to care for their patients if they become pregnant.

A gynecologic visit entails a breast examination and a pelvic examination. During the pelvic examination, a gynecologist inserts a speculum (a two-bladed instrument) into the vagina to view the cervix and takes a Pap smear, which involves scraping some superficial cells from the cervix to check for cancerous or precancerous conditions. The gynecologist next places one hand in the vagina and the other on the lower abdomen to palpate (feel) the internal pelvic organs (uterus, Fallopian tubes, and ovaries). Unless a woman is unusually tense, the examination is relatively painless. The visit also includes a gynecologic history, which includes asking about any problems or concerns the patient may have regarding her reproductive system. A woman may also be advised regarding birth control (contraception) or pregnancy.

Applications and Products

Obstetrics and gynecology have developed markedly since the 1960s. Technological advances, such as ultrasound and endoscopy, have dramatically changed patient care. New medications have been developed to both prevent and increase the likelihood of pregnancy and treat numerous diseases and conditions. The understanding of disease processes has also grown. More appropriate and beneficial techniques have replaced older ones.

Obstetrics. Most pregnancies progress uneventfully through delivery. However, complications can arise suddenly. The majority of women deliver vaginally. Some of these deliveries are assisted by the use of forceps or a vacuum extractor (a suction device applied to the fetal head). Some deliveries are conducted via a cesarean section (operative delivery) because of problems that arise during labor or the intrapartum period. Common reasons for cesarean sections include lack of progress during labor or the development of fetal distress.

Modern-day obstetrical care involves a great deal of technology. Obstetricians visualize the development of the fetus via ultrasound. This modality does not involve X-rays and is virtually harmless to the fetus and mother. Ultrasound can be used to evaluate fetal growth and to detect genetic abnormalities and the presence of multiple fetuses. About ten to twelve weeks into the pregnancy, chorionic villus sampling may be done to test for genetic defects in the fetus. In this procedure, ultrasound is used to guide a needle or catheter into the placenta and remove a small piece of tissue adjacent to the fetus. Amniocentesis may be used for genetic testing at about fourteen to eighteen weeks into the pregnancy. In amniocentesis, ultrasound is used to guide a needle into the fetal sac (amnion) to withdraw fluid for genetic analysis.

Fetal monitoring involves recording the fetal heart rate on a continuous roll of graph paper and can be conducted during pregnancy and labor. If a problem is noted, appropriate treatment or intervention can be initiated. For example, an obstetrician can induce (start) or augment (stimulate) labor with a variety of medications. A medication commonly used to promote labor is Pitocin (synthetic oxytocin), which acts directly on the uterus to stimulate contractions. The medication is administered by an intravenous drip, and the amount of medication administered is titrated (adjusted) so that contractions are strong enough for labor to progress but not excessively strong. Excessively strong contractions could cause harm to the fetus (even death) and possible rupture of the uterus. Instead of inducing labor, an obstetrician can also perform a cesarean section.

Gynecology. In an office setting, gynecologists offer contraceptive (birth control) advice and modalities. Oral contraceptives (birth control pills) and intrauterine devices (IUDs) are popular methods for preventing pregnancy. Gynecologists can also advise patients regarding other contraceptive methods.

As women age, their ovarian function slows and stops, a condition is known as menopause. Menstrual flow may change and then cease. Annoying symptoms, such as hot flashes, dry skin, and mood changes, may accompany menopause and cause women to consult with gynecologists. Hormonal therapy or other medication may be prescribed to alleviate these symptoms.

Gynecologists often perform colposcopies when Pap smear results are abnormal. The colposcope is a microscope that magnifies the cervix. If cervical abnormalities are found, a gynecologist can remove them by cone biopsy, cryocautery (freezing), or the loop electrosurgical excision procedure (LEEP).

Gynecologists use ultrasound to aid in making diagnoses. Ultrasound can detect fibroid growths on the uterus and ovarian cysts. Cancerous cysts are more likely to have multiple cavities. Therefore, ultrasound may detect the likelihood of a malignancy before surgery. Ultrasound can also measure the thickness of the endometrium (uterine lining). A thickened endometrium might indicate a cancerous condition. Fertility specialists commonly use ultrasound for in vitro fertilization. With ultrasound guidance, the specialist can insert a needle through the vaginal wall and into an ovarian follicle, which contains an ovum (egg). The ovum is aspirated into the needle and then fertilized with sperm. After an embryo develops, it is inserted into the uterine cavity to grow.

Gynecologic surgery is limited to the female reproductive system. A common gynecologic procedure is dilatation and curettage (D&C), which involves dilating the cervix (opening the womb) and scraping the uterine lining (endometrium). This procedure is done for diagnostic purposes and to control bleeding.

Some problems for which a D&C was previously performed are now diagnosed or treated by hysteroscopy (the insertion of a hysteroscope into the uterine cervix for viewing the interior of the uterus). A small piece of tissue (biopsy) can be removed for evaluation of an abnormality, such as endometrial cancer (cancer of the uterine lining). Growths, such as fibroid tumors (benign growths that can cause pain or bleeding), can be removed, and abnormalities of the cavity can be corrected.

A hysterectomy involves the removal of the uterus. Sometimes, this can be performed via the vagina (vaginal hysterectomy). Some hysterectomies are done because of fibroids that can cause pain or bleeding. Sometimes, a hysterectomy can be avoided by removing only the fibroids (myomectomy). Other common procedures are a salpingo-oophorectomy (removal of a tube and ovary) and vaginal repair surgery (vaginal damage is usually the result of childbirth).

Several gynecologic procedures, including a hysterectomy, are done with a laparoscope. Laparoscopy is often done to solidify a portion of the Fallopian tubes for women who do not wish to have children.

Careers and Course Work

To become a specialist in obstetrics and gynecology, an individual must first obtain a Bachelor's degree. As long as the course requirements for medical school are met, this degree can be in any field. Next, the individual must earn a medical degree from a four-year medical school, followed by an internship and residency program for specialty training. Some specialists limit their practice solely to either obstetrics or gynecology. Some specialists receive additional training in a subspecialty, such as maternal-fetal medicine, infertility, or urogynecology (focused on the medical and surgical treatment of problems with the female urinary system).

The obstetrician-gynecologist has a variety of career opportunities. Entering private practice usually entails joining the practice of an established physician or group of physicians. Such groups may consist solely of obstetrician-gynecologists or contain specialists in various fields. The trend is away from solo practitioners and small group practices. Larger groups have the benefit of sharing equipment and other resources. Also, being part of a group allows doctors to share weekend and night calls. Larger groups often employ physician assistants and nurse practitioners to handle less complex problems. Opportunities exist for a career in academic medicine, including medical research and training medical students or resident physicians. Most obstetrician-gynecologists take written and oral examinations to become certified in the specialty. The specialty board in the United States (US) is the American Board of Obstetrics and Gynecology.

Social Context and Future Prospects

Any physician who deals with birth control and pregnancy may also be called on to deal with abortion. Abortion is a highly debated topic in many areas of the globe and an accepted procedure in others. Opinions range from the belief that life begins at the moment of conception and should not be disrupted under any circumstances to the view that it is a woman's right to terminate a pregnancy at any point up to full term. Some physicians will not perform an abortion under any circumstances, and some limit their practice to abortion and sterilization procedures. In June 2022, the US Supreme Court’s decision to overturn decades-long legislation in the landmark Roe v. Wade case in Dobbs v. Jackson Women’s Health Organization ensured the topic would likely remain controversial for the foreseeable future.

In the twenty-first century, surgical techniques continued to evolve, particularly in endoscopy (laparoscopy and endoscopy), where the use of robotics increased. Innovations in equipment led to new techniques. For example, during in vitro fertilization, traditionally, several embryos were implanted into the uterus because some were not expected to survive. However, this practice increased the likelihood of multiple births, which raised the risk of premature birth and miscarriage. Because of improvements in technology, a single embryo had a good chance of survival, and many physicians began implanting only one embryo. Ultrasound and other imaging methods allowed many birth defects to be diagnosed before birth, and intrauterine surgery evolved to correct these problems. Artificial intelligence (AI) also became useful to gynecology and obstetrics in the twenty-first century, as AI was used to detect fetal abnormalities and analyze mammogram data with increased accuracy.

The American College of Obstetricians and Gynecologists took steps to improve access to care for underserved communities, such as transgender individuals. The organization issued a recommendation in 2021 that members provide affirming and inclusive care and educate patients on relevant concerns, such as preventive care. It also stated it was the medical provider's responsibility to educate oneself on the needs of underserved communities, including available therapies and appropriate referrals.

Bibliography

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