Introduction to Obstetrics and Gynecology: Clinical Practice, Ethics, and Physical Examination

The Unique Nature of Obstetrics and Gynecology (OBGYN)

• OBGYN is distinguished from all other medical specialties by its dual nature as both a surgical subspecialty and a primary care provider.
• The Identity Crisis in OBGYN:     * Practitioners are surgically trained, yet for many healthy patients, an OBGYN (or a midwife/nurse practitioner in the field) serves as the primary source of care.     * Historical Context: In the mid-1990s, the President of the American College of Obstetricians and Gynecologists (ACOG) pushed for the field to be recognized as a primary care specialty, largely for profitability.     * Clinical Scope: While some practitioners treat general conditions like hypertension and depression in non-pregnant patients, some "purists" strictly limit their practice to obstetrics and gynecology.

Clinical Ethics and Pregnancy Conflicts

• Patient Autonomy vs. Fetal Health: Ethical conflicts arise when a pregnant patient must choose between their own health and the health of the pregnancy.     * Examples: A patient may choose to avoid radiation therapy or delay chemotherapy to protect the fetus, even at the risk of their own life.     * Patient Perspective: Decisions vary; some patients prioritize the pregnancy, while others prioritize their own survival. Both are considered valid clinical choices.
• Preeclampsia and Hypertensive Disorders:     * There are eight hypertensive disorders of pregnancy. Preeclampsia is the most prominent and is known as the "syndrome of questions" due to its poorly understood nature.     * Treatment: The definitive treatment for preeclampsia is delivery.     * Ethical Dilemma of Delivery:         * Early delivery may save the patient from severe illness/death but risks the life of the fetus if performed before viability.         * Viability Threshold: A fetus is considered likely to survive outside the uterus at $24\,weeks$, and sometimes as early as $22\,weeks$, though with high risk.         * Gestational Age and Severity: Similar to breast cancer (where earlier diagnosis in younger patients often indicates a more aggressive, familial course), earlier onset of preeclampsia in gestation typically indicates a more severe clinical course.
• Bioethical Consultation: OBGYN uses bioethical teams more frequently than any other specialty, except for end-of-life care or the Intensive Care Unit (ICU).

The Clinical Encounter: Privacy and Vulnerability

• Emotional Range: Practitioners manage both the "happiest days" (delivery, cancer remission, escaping abuse) and "great crisis" (pregnancy loss, intrauterine fetal demise at $38\,weeks$, STI diagnoses).
• Sacred Trust: Patients often share information with OBGYNs that they have never told anyone else, turning the doctor-patient interaction into a "sacred moment."
• The Turtle Metaphor for Vulnerability:     * A patient in a hospital gown undergoing a pelvic exam is metaphorically like a turtle without its shell: exposed, uncomfortable, and vulnerable.     * Clinical Tip: To mitigate this, clinicians should consider talking to the patient while they are still fully dressed to reduce the perceived power distance and vulnerability before the physical exam.
• Privacy and Honest History:     * Clinicians must strive to interview the patient alone. This allows for an accurate history that might otherwise be withheld in front of a partner or parent.     * Anecdote: A $15\,year\,old$ patient admitted for a second-trimester termination provided a different history of her prior pregnancies once her boyfriend was asked to wait outside. This information was critical for her clinical outcome.

Salis’ Deadly Triad and Medical Error

• The Case Study: A $23\,year\,old$ patient of color died a few hours after a normal vaginal delivery. She presented with severe right upper quadrant pain. Residents dismissed her symptoms as being "dramatic" and gave her Ativan.
• The Real Diagnosis: The patient died from HELLP Syndrome ($Hemolysis$, $Elevated\,Liver\,function\,testing$, $Low\,Platelets$), a rare hypertensive disorder occurring in approximately $1\%$ of pregnancies.
• Salis’ Deadly Triad:     * 1. Arrogance.     * 2. Laziness.     * 3. Stupidity.     * According to the lecturer, arrogance is always present in these medical errors. The case highlights systemic issues of racism and misogyny within healthcare.

Obstetric History: Gravidity and Parity

• Gravidity: The total number of times a patient has been pregnant in their lifetime, including the current pregnancy.
• Parity: A four-column shorthand ($TPAL$) describing the outcome of those pregnancies:     * Column 1 (Term): Full-term deliveries ($\ge 37\,weeks$).     * Column 2 (Preterm): Deliveries between $20\,weeks$ and $36\,weeks$ and $6\,days$.     * Column 3 (Abortions/Losses): Fetal losses or terminations before $20\,weeks$.     * Column 4 (Living): The number of children currently living ($living\,beyond\,28\,days$ is the obstetric relevance).
• Clinical Math:     * Pregnancy length is $280\,days$ or $40\,weeks$.     * Last Menstrual Period (LMP): This must be recorded as the first day of the last menstrual period, not when it ended.     * Example: A patient pregnant on May 21st with an LMP of February 21st is $13\,weeks$ and $0\,days$ pregnant ($52\,weeks / 4 = 13\,weeks$).
• Neonatal Mortality Factors:     * The primary causes of death in the first $28\,days$ are Sepsis (most commonly caused by Group B Strep) and Congenital Anomalies.

Gynecologic History and Puberty Trends

• Menarche: The age of the first period.     * Current Average Age: $12\,years$ (down from $13\,years$ five decades ago).     * Trends: Some patients now start as early as age $5$ or $8$. Early menarche ($age\,8$) combined with late menopause ($age\,55$) results in increased lifetime estrogen exposure, raising the risk of endometrial cancer.     * Potential Causes for Early Puberty:         * Obesity (estrogen is stored in fat tissue).         * Nutritional factors/hormones in food.         * Climate change (historically, populations near the equator undergo earlier puberty).
• Menstrual Cycle Parameters:     * Normal Cycle Length: $21$ to $35\,days$ (calculated from the first day of one period to the day before the next).     * Bleeding Duration: Normal ranges from a few hours up to $7\,days$.
• Sexual History:     * Clinicians should ask about the number of lifetime partners (HPV risk) and age of first sexual encounter (using trauma-informed language).     * Behavior vs. Identity: A patient identifying as a lesbian may still have a partner assigned male at birth or a transgender male partner capable of impregnation.

Cervical Cancer Screening Guidelines (ACOG 2024 Updates)

• Screening Initiation: Do not screen patients under age $21$, regardless of sexual activity. HPV in young patients is usually cleared by the immune system within two years.
• Ages 21–29: Screening via cervical cytology (Pap test) every $3\,years$.
• Ages 30–65: Three options:     1. Primary High-Risk HPV (hrHPV) Screening (Preferred): Every $5\,years$.     2. Co-testing (Pap + hrHPV): Every $5\,years$.     3. Cytology alone: Every $3\,years$.
• Non-Average Risk Patients (Require individualized screening):     * Immunocompromised patients (HIV, transplant recipients, systemic steroids).     * Those with a history of precancerous (CIN 2 or 3) or cancerous lesions.     * DES Exposure: Patients exposed to Diethylstilbestrol in utero (used to prevent pregnancy loss) are at risk for clear cell adenocarcinoma of the vagina and must be screened twice a year.
• Cessation of Screening: At age $65$ (if prior screens were negative) or after a hysterectomy for non-cancerous reasons (e.g., fibroids).

Intimate Partner Violence (IPV)

• Statistics: Up to $70\%$ of patients worldwide are affected. It occurs in over $10\%$ of pregnancies.
• Homicide: Murder is the leading cause of death for pregnant patients in the United States.
• Risk Factors: Being younger (risk of murder doubles if age $< 25$), low socioeconomic status, substance use, and being indigenous.
• Cycle of Abuse:     1. Tension Building: Something upsets the assailant.     2. Incident: Physical, sexual, or emotional lashing out.     3. Honeymoon Phase: Assailant expresses remorse, "love bombs" the survivor, and promises change. This phase creates confusion and lowers the survivor's self-esteem.
• Reproductive Coercion: Limiting access to contraception, throwing out pills, or forcibly removing IUDs. Depo-Provera is the only truly "invisible" contraceptive.
• Clinical Approach:     * Screening for IPV may have no statistical benefit if not done with absolute privacy.     * Never tell a patient to "just get out." The time of leaving is statistically the most dangerous and likely time for a patient to be killed.     * Offer resources and validation: "I am concerned for you" and "You don't deserve this."

The Physical Exam: Techniques and Anatomy

• Cervical Anatomy:     * External Os: The visible opening into the endocervical canal.     * Internal Os: The border between the cervix and the uterus.     * Transformation Zone: The area where columnar cells change into squamous cells via squamous metaplasia. This is the most vulnerable area for HPV infection.     * Nulliparous vs. Parous: A nulliparous (never delivered) os is round; a parous (has delivered) os is a transverse slit.
• Abdominal/Obstetric Exam:     * Fundal Height: Measured from the symphysis pubis to the top of the fundus. After $20\,weeks$, the height in centimeters should roughly equal the weeks of gestation ($\pm 2\,cm$).     * Landmarks: At $20\,weeks$, the fundus is at the level of the umbilicus.
• Leopold’s Maneuvers: Used to determine fetal position after $20\,weeks$.     * 1st Maneuver: Determine if the lie is longitudinal or transverse.     * 2nd Maneuver: Locate the fetal spine (feels firm and regular).     * 3rd Maneuver: Identify the presenting part (the head feels like a hard ball).     * Heart Tones: Best heard through a Doppler stethoscope at the back of the fetal neck.

Questions & Discussion

• Q: Why did OBGYN become a primary care specialty?     * A: Profitability was a major driver in the 1990s, though many clinicians remain surgical purists.
• Q: Is a routine pelvic exam (the "yearly") useful?     * A: There is no conclusive evidence that a routine, asymptomatic pelvic exam is beneficial or provides useful screening data, though it remains common practice.
• Q: What if a patient under 21 is sexually active? Should they get a Pap smear?     * A: No. HPV infections in this age group generally clear on their own. Testing often leads to unnecessary, traumatic procedures for lesions that would have resolved naturally.
• Q: How hard do you press during Leopold’s?     * A: Firmly enough to feel the mass, but not so hard as to cause pain. The fetus is well-protected by amniotic fluid.
• Q: If a patient has twins, are they facing each other?     * A: It depends on the day and the hour; they move frequently.