Obstetrics and gynaecology
Obstetrics and gynaecology (or obstetrics and gynecology; often abbreviated to OB/GYN, OBG, O&G or Obs & Gynae) is the medical speciality dealing with fields of obstetrics and gynaecology through only one postgraduate training programme. This combined training prepares the practicing OB/GYN to be adept at the care of female reproductive organs's health and at the management of obstetric complications, even through surgery.
The training required to practice medicine as an OB/GYN is extensive, although the exact duration of training varies by country. In the United Kingdom, training lasts seven years. In the United States, four years in residency are required for MDs and DOs. In Australia, the residency training period is six years, matched only by neurosurgery and maxillofacial surgery. In India, post graduate training in obstetrics and gynecology is in the form of a two-year diploma course (DGO) or a three-year (MD or MS). Some OB/GYN surgeons elect to do further subspecialty training in programs known as fellowships after completing their residency training, although the majority choose to enter private or academic practice as general OB/GYNs. Fellowship training can range from one to four years in duration, and usually have a research component involved with the clinical and operative training.
All obstetricians are trained gynecologists, although the reverse is not necessarily true. However, some OB/GYNs may choose to drop the obstetric component of their practice and focus solely on gynecology, especially as they get older. This decision is often based on the double burden of very late hours and, depending on the country, high rates of litigation.
This combined training prepares the practicing OB/GYN to be adept at the surgical management of the entire scope of clinical pathology involving female reproductive organs, and to provide care for both pregnant and non-pregnant patient.
Examples of subspecialty training available to physicians in the US are:
- Maternal-fetal medicine – an obstetrical subspecialty, sometimes referred to as perinatology, that focuses on the medical and surgical management of high-risk pregnancies and surgery on the fetus with the goal of reducing morbidity and mortality.
- Reproductive endocrinology and infertility – a subspecialty that focuses on the biological causes and interventional treatment of infertility
- Gynaecological oncology – a gynaecologic subspecialty focusing on the medical and surgical treatment of women with cancers of the reproductive organs
- Female pelvic medicine and reconstructive surgery – a gynaecologic subspecialty focusing on the diagnosis and surgical treatment of women with urinary incontinence and prolapse of the pelvic organs. Sometimes referred to by laypersons as "female urology"
- Advanced laparoscopic surgery
- Family planning – a gynaecologic subspecialty offering training in contraception and pregnancy termination (abortion)
- Paediatric and adolescent gynaecology
- Menopausal and geriatric gynaecology
Of these, only the first four are truly recognized sub-specialties by the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Obstetrics and Gynecology (ABOG). The other subspecialties are recognized as informal concentrations of practice. To be recognized as a board-certified subspecialist by the American Board of Obstetrics and Gynecology or the American Osteopathic Board of Obstetrics and Gynecology, a practitioner must have completed an ACGME or AOA-accredited residency and obtained a Certificate of Added Qualifications (CAQ) which requires an additional standardized examination.
Additionally, physicians of other specialties may become trained in Advanced Life Support in Obstetrics (ALSO), a short certification that equips them to better manage emergent OB/GYN situations.
Recent shortage in US
From 2000 through 2004, American medical students were increasingly choosing not to specialize in obstetrics. This led to a critical shortage of obstetricians in some states and often fewer health care options for women — although it did not lead to higher average salaries. However, beginning in 2004, increasing state legislation mandating tort reform combined with the ACGME's decision to limit resident work hours led to a gradual resurgence in the number of medical students choosing OB/GYN as a specialty. In the medical residency match for 2007, only six spots in OB/GYN training programmes remained vacant throughout the entire United States; a record low number, and one that puts OB/GYN on par in terms of competitiveness with some other surgical specialties. According to the Association of American Medical Colleges report "The State of Women in Academic Medicine," 83 percent of OB/GYN residents are female.
The salary of an obstetrician varies by country. In the United States, the salary ranges from $200,000 to $339,738.
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Prior to the 18th century, caring for pregnant women in Europe was confined exclusively to women, and rigorously excluded men. The expectant mother would invite close female friends and family members to her home to keep her company. Skilled midwives managed all aspects of the labour and delivery. The presence of physicians and surgeons was very rare and only occurred once a serious complication had taken place and the midwife had exhausted all measures to manage the complication. Calling a surgeon was very much a last resort and having men deliver women in this era whatsoever was seen as offending female modesty.
Leading up to the 18th century
Obstetrics prior to the 18th and 19th centuries was not recognized on the same level of importance and professionalism as other medical fields, until about two hundred years ago it was not recognized as a medical practice. However, the subject matter and interest in the female reproductive system and sexual practice can be traced back to Ancient Greece and even to Ancient Egypt. Soranus of Ephesus sometimes is called the most important figure in ancient gynecology. Living in the late first century A.D. and early second century he studied anatomy and had opinions and techniques on abortion, contraception –most notably coitus interruptus– and birth complications. After the death of Soranus, techniques and works of gynecology declined but very little of his works were recorded and survived to the late 18th century when gynecology and obstetrics reemerged.
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, medical professionals began to understand the anatomy of the uterus and the physiological changes that take place during labour. The introduction of forceps in childbirth also took place during the 18th century. All these medical advances in obstetrics were a lever for the introduction of men into an arena previously managed and run by women—midwifery.
The addition of the male-midwife is historically a significant change to the profession of obstetrics. 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. In France these male-midwives were referred to as "accoucheurs". This title was later on lent to male-midwives all over Europe. The founding of lying-hospitals also contributed to the medicalization and male-dominance of obstetrics. These lying-hospitals were establishments where women would come to have their babies delivered, which had prior been unheard of since the midwife normally came to home of the pregnant woman. This institution provided male-midwives or accoucheurs with an endless number of patients to practice their techniques on and also was a way for these men to demonstrate their knowledge.
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 men-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.
Even 18th century physicians expected that obstetrics would continue to grow, the opposite happened. Obstetrics entered a stage of stagnation in the 19th century, which lasted until about the 1880s. The central explanation for the lack of advancement during this time was substantially due to the rejection of obstetrics by the medical community. The 19th century marked an era of medical reform in Europe and increased regulation over the medical profession. Major European institutions such as The College of Physicians and Surgeons 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. 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.
By the late 19th century the foundation of modern day obstetrics and midwifery began develop. Delivery of babies by doctors became popular and readily accepted, but midwives continued to play a role in childbirth. Midwifery also changed during this era due to increased regulation and the eventual need for midwives to become certified. 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.
As midwifery began to develop so did the profession of obstetrics near the end of the century. Childbirth was no longer unjustifiably despised by the medical community as it once had been at the beginning of the century. But the specialty was still behind in its development stages in comparison to other medical specialities, and remained a generality in this era. 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 anesthesia, which paved the way for the mainstream introduction and later success of the Caesarean Section.
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, at the time commonly known as childbed fever. In the 1800s Dr. 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%. So it was concluded that it was physicians who had been spreading disease from one laboring 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.
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”.
American surgeons are responsible for many of the advancements of Gynecology and Obstetrics –these two fields overlapped greatly as they both gained attention in the medical field– at the end of the nineteenth century through the development of such procedures as the ovariotomy. These procedures then were shared with European surgeons who replicated the surgeries. It should be noted that this was a period when antiseptic, aseptic or anesthetic measures were just being introduced to surgical and observational procedures and without these procedures surgeries were dangerous and often fatal. Following are two surgeons noted for their contributions to these fields include Ephraim McDowell and James Marion Sims.
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 thirty-one more years. 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. 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. By the middle of the nineteenth century this procedure was successfully performed in Europe by English surgeons Sir Spencer Wills and Charles Clay as well as French surgeons Eugène Koeberlé, Augeste Nélation and Jules Peau.
J. Marion Sims was the surgeon responsible for being the first treating a vesicovaginal fistula –a condition linked to many caused mainly by prolonged pressing of the fetus 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. These women were the first patients of modern gynecology. One of the women he operated on was named Anarcha, the woman he first treated for a fistula.
Historical role of gender
Women and men inhabited very different roles in natal care up to the 18th century. 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. Many of the theories of what caused menstruation prevailed from Hippocratic philosophy. Midwives of this time were those assisted in the birth and care of both born and unborn children, and as the name suggests this position held mainly by women.
During the birth of a child, men were rarely present. Women from the neighborhood or family would join in on the process of birth and assist in many different ways. 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.
Men were introduced into the field of obstetrics in the nineteenth century and resulted in a change of the focus of this profession. Gynecology 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. 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. But, there was also a large blame of the uterus for completely unrelated conditions. This led to many social consequences of the nineteenth century.
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-  International Federation of Gynaecology and Obstetrics (FIGO)
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