Obstetrics and gynecology as subject Organization of obstetric

Obstetrics and gynecology as subject. Organization of obstetric care. The main stages of obstetrics and gynecology development. Role of family doctor in the prevention of perinatal diseases and death. Lecture 1 Petrenko N. V. , MD, Ph. D 1

Obstetrics and gynecology • 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. 2

Gynaecology or gynecology • is the medical practice dealing with the health of the female reproductive system. • Literally, outside medicine, it means "the science of women «Almost all modern gynaecologists are also obstetricians • Etymology • The word "gynaecology" comes from the Greek ancient Greek gyne, γυνή, modern Greek gynaika, γυναίκα, meaning woman + logia meaning study, so gynaecology literally is the study of women. 3

perinatology or Maternal-Fetal medicine (MFM) • is the branch of obstetrics that focuses on the medical and surgical management of high-risk pregnancies. • Obstetricians who practice maternal-fetal medicine are also known as perinatologists. • This is a subspecialty to obstetrics and gynecology mainly used for patients with high-risk pregnancies. 4

obstetrics and gynecology • medical/surgical specialty concerned with the care of women from pregnancy until after delivery and with the diagnosis and treatment of disorders of the female reproductive tract. • The medical care of pregnant women (obstetrics) and of female genital diseases (gynecology) developed along different historical 5 paths.

ORIGINS OF OBSTETRICS • • • Gynecology as a branch of medicine dates back to Greco-Roman civilization, if not earlier. The renewal of interest in diseases of women is shown in the huge encyclopaedia of gynecology issued in 1566 by Caspar Wolf of Zürich. The earliest birth attendants were women. In ancient mythology, goddesses (but not gods) were present at deliveries. In “primitive” tribes studied by anthropologists in the last century, the labouring woman would be accompanied by her mother or other female relative. Prehistoric figures and ancient Egyptian drawings show women giving birth in the sitting or squatting position. Birthing stools and midwives are also mentioned in the Old Testament. 6

History • • • The Kahun Gynaecological Papyrus is the oldest known medical text of any kind. Dated to about 1800 B. C. , it deals with women's complaints —gynaecological diseases, fertility, pregnancy, contraception, etc. The text is divided into thirty-four sections, each section dealing with a specific problem and containing diagnosis and treatment, no prognosis is suggested. The Hippocratic Corpus contains several gynaecological treatises dating to the 5 th/4 th centuries BC. The gynaecological treatise Gynaikeia by Soranus of Ephesus (1 st/2 nd century AD) is extant. 7

ORIGINS OF OBSTETRICS • The writings of Hippocrates in the fifth century BC include a description of normal birth. • Instrumental delivery was restricted to stillborn babies and involved the use of hooks, destructive instruments, or compressive forceps. • Such instruments were described in Sanskrit texts and were known in Arabia, Mesopotamia, and Tibet. • Instrumental intervention in obstructed labour probably carried a high cost in terms of maternal mortality. 8

ORIGINS OF OBSTETRICS • • • Soranus of Ephesus (AD 98– 138) described antenatal care, labour, and the management of malpresentation by internal version and breech extraction. He advised that during labour a woman should be nursed in bed until delivery was imminent, and then moved to the birthing chair, when the midwife would sit opposite her, encouraging her to push, before receiving the baby on to papyrus or cloth. Soranus' writings formed the basis of the “Moschion”, a Latin manuscript in the sixth century AD, but little more was added to obstetric knowledge until the invention of printing 900 years later. 9

ORIGINS OF OBSTETRICS • The history of obstetrics is inextricably linked with the history of midwifery. • obstetrix was the Latin word for midwife: it is thought to derive from obstare (to “stand before”), because the attendant stood in front of the woman to receive the baby. • Only in the 20 th century did the subject taught in medical schools change its name from “midwifery” to “obstetrics”, perhaps because a Latin name seemed more academic than the Anglo-Saxon, derived from mid, “with”, and wyf, “woman”. 10

ORIGINS OF OBSTETRICS • • The first obstetric pamphlets were printed in Latin or in German in the latter part of the 15 th century but made little impact. In 1513, however, an obstetric textbook appeared which became a bestseller. Der Schwangern Frauen und Hebamen Rosengarten, known as “The Rosengarten”, was translated into Dutch in 1516 and reprinted many times in Dutch and German over subsequent decades. It was also translated into several other languages, including French and English. 11

ORIGINS OF OBSTETRICS • • During the 16 th century the great French military surgeon Ambroise Paré (1510– 90) founded a school for midwives in Paris. Paré wrote about podalic version and breech extraction and about caesarean section, which he is said to have either performed or supervised not only after the death of the mother but also, at least twice, on living women. One of Pare's pupil midwives went on to attend the French court and one of the babies she delivered—a girl named Henrietta Maria—became Queen of England at the age of 16 when she married King Charles I in 1625. 12

ORIGINS OF OBSTETRICS • • • Obstetrics had for a long time been the province of female midwives, but in the 17 th century, European physicians began to attend on normal deliveries of royal and aristocratic families; from this beginning, the practice grew and spread to the middle classes. The invention of the forceps used in delivery, the introduction of anesthesia, and Ignaz Semmelweis’ discovery of the cause of puerperal (“childbed”) fever and his introduction of antiseptic methods in the delivery room were all major advances in obstetrical practice. Asepsis in turn made cesarean section, in which the infant is delivered through an incision in the mother’s uterus and abdominal wall, a feasible surgical alternative to natural childbirth. 13

ORIGINS OF OBSTETRICS • The 18 th 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 18 th century. 14

ORIGINS OF OBSTETRICS • • • After Nufer, the first caesarean sections with survival of the mother were performed in Ireland by Mary Donally in 1738; in England by Dr James Barlow in 1793; and in America by Dr John Richmond in 1827. The “first” in the British Empire outside the British Isles was performed in South Africa before 1821 by James Miranda Barry, though in fact caesarean sections had been performed in Africa by indigenous healers for many years. All these operations, however, were performed without anaesthesia. In the mid-19 th century death rates remained high and caesarean section was often combined with hysterectomy. In the 1880 s, with the advent of asepsis, a conservative operation was developed and the “classical” operation —a vertical incision in the upper part of the uterus—became more frequently used. This incision does not heal well, however, and in 1906 the modern “lower segment” operation was introduced, which carries less risk of subsequent rupture. 15

ORIGINS OF OBSTETRICS • By the early 19 th century, obstetrics had become established as a recognized medical discipline in Europe and the United States. • At the start of the 19 th century childbirth was still dangerous to women and it remained so, despite several advances, until well into the 20 th century. • Among the poor, rickets caused pelvic deformities. • Maternal death affected all social classes, one in 200 pregnancies ended in the death of the mother because of puerperal fever 16

ORIGINS OF OBSTETRICS • • The contagious nature of puerperal fever had been recognised by Alexander Gordon. Aberdeen experienced an epidemic of puerperal fever from 1789 to 1792, and Gordon published his Treatise on the Epidemic of Puerperal Fever in Aberdeen in 1795. He realised that the disease was transmitted from one case to another by doctors and midwives, and that there was a close relationship between puerperal fever and erysipelas (later found to be caused by the streptococcus). 17

ORIGINS OF OBSTETRICS • Eventually others reached the same conclusion, including Oliver Wendell Holmes (1809– 94), the American doctor and writer. • Four years later, his Hungarian contemporary Ignaz Semmelweiss (1818 – 65), working in Vienna. Semmelweiss, concluded that cadaveric material caused infection, and he made his students wash their hands in chlorinated lime between the postmortem room and the labour ward. Within months during 1847 he reduced deaths in his unit to a level similar to that in the neighbouring midwife-led unit, where staff did not attend postmortems. 18

obstetrics and gynecology • The two great advances that finally overcame such opposition and made gynecologic surgery generally available were the use of anesthesia and antiseptic methods. • The separate specialty of gynecology had become fairly well established by 1880; its union with the specialty of obstetrics, arising from an overlap of natural concerns, began late in the century and has continued to the present day. 19

ORIGINS OF OBSTETRICS • • In the 20 th century, obstetrics developed chiefly in the areas of fertility control and the promotion of healthy births. The prenatal care and instruction of pregnant mothers to reduce birth defects and problem deliveries was introduced about 1900 and was thereafter rapidly adopted throughout the world. Beginning with the development of hormonal contraceptive pills in the 1950 s, obstetrician-gynecologists have also become increasingly responsible for regulating women’s fertility and fecundity. With the development of amniocentesis, ultrasound, and other methods for the prenatal diagnosis of birth defects, obstetrician-gynecologists have been able to abort defective fetuses and unwanted pregnancies. At the same time, new methods for artificially implanting fertilized embryos within the uterus have enabled obstetrician-gynecologists to help previously infertile couples to have children. 20

Perinatal/Maternal Mortality • In the developed world, by contrast, in the second half of the 20 th century attention shifted from the mother to the fetus. Two developments allowed this to happen. Fetal monitoring in labour became possible by detecting the fetal electrocardiogram and by sampling fetal scalp blood. 21

HISTORY • A combination of innovations over the last one hundred years have contributed to this progress, including, – Antibiotics – The ability to safely transfuse blood products – The increasing safety of cesarean delivery and improved anesthesia techniques – The widespread use of uterotonics and safer methods of induction of labor – The introduction of corticosteroids to enhance fetal lung maturity – The widespread use of anti-D immune globulin to prevent Rhallomunization – The practice of surveillance for and early intervention (i. e. delivery) in cases of preeclampsia/hypertension – Advances in adult and neonatal intensive care – Introduction of ultrasonography and other advanced antenatal monitoring techniques 22

Pregnancy has always carried a risk to the mother's life. • The Taj Mahal commemorates a queen who died having her 12 th child in 1635. • Thomas Jefferson, the US president, lost his wife after a delivery in 1782. • Charlotte Bronte died of hyperemesis gravidarum in 1855. • In 1865 Isabella Maysom (“Mrs Beeton”) died at the age of 29 after her fourth delivery. • In 19 th century Britain one pregnancy in 200 led to the death of the mother and this figure still applied in the 1930 s. 23

Perinatal/Maternal Mortality • In developing countries, however, maternal mortality is still a major problem. • Across the globe, one woman dies of pregnancy every minute of every day. • The causes are sepsis, haemorrhage, hypertensive disease, and unsafe abortion—the same causes that were common in Britain 70 years ago. 24

Perinatal/Maternal Mortality • Perinatal mortality is the sum of fetal (from 22 weeks until delivery) and neonatal (until 28 days of age) mortality. • Maternal mortality includes maternal deaths during pregnancy and within 42 days of delivery. 25

Historic Reduction of Perinatal/Maternal Mortality 26

Perinatal/Maternal Mortality (deaths/100, 000 live births), 2012 Belarus 19 Somalia 1, 000 Albania, Romania 27 Sierra Leone, Central African Republic 890 Turkey, Luxembourg 20 Cameroon 690 United Kingdom, Serbia, Slovenia, Denmark 12 Nigeria 630 Malta, Montenegro, Portugal, Belgium, France, Switzerland 8 Niger 59 Germany, Norway 7 Zimbabwe 57 Netherlands, Spain, Slovakia, Ireland 6 Kenya 360 Ghana 350 Morocco 100 Egypt 66 Yemen 200 Syria 70 Iraq 63 Saudi Arabia 24 United Arab Emirates 1227 72 Israel

Perinatal/Maternal Mortality • • • Every day, almost 800 women die in pregnancy or childbirth. . Every two minutes, the loss of a mother shatters a family and threatens the wellbeing of surviving children. Evidence shows that infants whose mothers die are more likely to die before reaching their second birthday than infants whose mothers survive. And for every woman who dies, 20 or more experience serious complications. Of the hundreds of thousands of women who die during pregnancy or childbirth each year, 90 per cent live in Africa and Asia. The majority of women are dying from – – – • severe bleeding, infections, eclampsia, obstructed labour and the consequences of unsafe abortions- -all causes for which we have highly effective interventions. 28

Safe motherhood • • Working for the survival of mothers is a human rights imperative. It also has enormous socio-economic ramifications – and is a crucial international development priority. Both the International Conference on Population and Development and Millennium Development Goals call for a 75 per cent reduction in maternal mortality between 1990 and 2015. This three-pronged strategy is key to the accomplishment of the goal: – – – • All women have access to contraception to avoid unintended pregnancies All pregnant women have access to skilled care at the time of birth All those with complications have timely access to quality emergency obstetric care In countries such as China, Cuba, Egypt, Jamaica, Malaysia, Morocco, Sri Lanka, Thailand Tunisia, significant declines in maternal mortality have occurred as more women have gained access to family planning and skilled birth attendance with backup emergency obstetric care. Many of these countries have halved their maternal deaths in the space of a decade. 29

Safe motherhood 30

What is Safe Motherhood? • The Safe Motherhood Initiative is a worldwide effort that aims to reduce the number of deaths and illnesses associated with pregnancy and childbirth. • Ways to achieve safe motherhood include: – Skilled attendance at all births – Access to quality emergency obstetrical care – Access to quality reproductive health care, including family planning and safe post-abortion care 31

Safe motherhood 32

Definitions of Levels of Care • As put forth by the Lord Dawson Report (Britain, 1920 s) – Primary Care is principally concerned with common, ambulatory health concerns and preventive care – Secondary Care principally involves specialist involvement and treatment – Tertiary Care deals with rare and complex medical problems 33

Structuring a Health Care System Based on 3 Levels of Care • There are two principal ways to organize a health care system based on the three levels of care: – The Regionalized Model • Example: The British National Health Service – The Dispersed Model • Example: The United States 34

The Regionalized British NHS Model • Patients enter the health care system via their General Practitioner at the Primary Care level • General Practitioners are responsible for defined geographic areas • This places a greater emphasis on community health and team based health care 35

The Regionalized British NHS Model Tertiary Care = subspecialists working at large regionalized medical centers Secondary Care = specialists providing consultations and hospital care Primary Care = general practitioners focusing on ambulatory and preventive care Mode of Care and Administration 500, 000+ people 50, 000 to 500, 000 people 5000 to 50, 000 people Population Served 36

The Dispersed U. S. Health Care Model • The US health model is a less structured approach • Traditionally, patients had the ability start out either by seeing a primary care provider or referring themselves directly to a specialist • Hospitals in the US are also less rigidly established 37

The Dispersed U. S. Health Care Model Elite Academic Medical Centers providing highly specialized care Majority of hospitals providing secondary and tertiary care Small, generally rural, medical centers lacking specialized care 38

Comparisons of the models Regionalized Model Dispersed Model Patients first interact with a GP Less rigid structure with direct consultation of specialists Patients need referrals to see specialists More hospital technologies in closer proximity GPs work closely with practice nurses, home health visitors & public health nurses Specialist heavy care contributing to higher cost of care Team based approach allows for greater emphasis on community health Potential for decreased quality of care 39

Primary Care in the Health Care Workforce • Trends in the United States clearly reveal that the number of residents choosing a primary care specialty is on the decline • Compare this to the United Kingdom where 2/3 of physicians work as general practitioners • Why is the decline in the Primary Care workforce in the United States so alarming? 40

Conclusion • Primary care is not only essential to the health of individuals but it improves the entire health care system • The US needs to improve the way that it structures its health care system and provide more of an emphasis on primary care • Every medical student can engage the political system and effect necessary 41 change

Family physician • Family physicians and obstetricians should collaborate on the design, implementation and evaluation of the training of family practice residents in obstetrics-gynecology. • A Knowledge of diagnosis and management – Normal female growth and development, and variants – Appropriate history and physical examination for all age groups 42

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