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, PhD
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
paths.
5
ORIGINS OF OBSTETRICS
•
•
•
•
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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 5th/4th centuries BC.
The gynaecological treatise
Gynaikeia by Soranus of
Ephesus (1st/2nd 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 20th 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
15th 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 16th 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
17th 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 18th century
marked the beginning of
many advances in
European midwifery.
These advances in
knowledge were mainly
regarding the physiology
of pregnancy and labour.
By the end of the century
the anatomy of the uterus
and the physiological
changes that take place
during labour began to be
understood by medical
communities.
• The introduction of
forceps in childbirth also
took place during the 18th
century.
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-19th century death rates remained
high and caesarean section was often
combined with hysterectomy.
In the 1880s, 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 19th century,
obstetrics had become
established as a recognized
medical discipline in Europe
and the United States.
• At the start of the 19th
century childbirth was still
dangerous to women and it
remained so, despite
several advances, until well
into the 20th 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 20th 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
1950s, 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 20th
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 12th 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 19th century Britain one pregnancy in 200 led to the
death of the mother and this figure still applied in the
1930s.
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:
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–
–
•
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 and
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, 1920s)
– 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
change
41
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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