Significant Points

• Many physicians and surgeons work long, irregular hours.
• Acceptance to medical school is highly competitive.
• Formal education and training requirements—typically 4 years of undergraduate school, 4 years of medical school, and 3 to 8 years of internship and residency—are among the most demanding of any occupation, but earnings are among the highest.
• Job opportunities should be very good, particularly in rural and low-income areas.

Nature of the Work

Physicians and surgeons diagnose illnesses and prescribe and administer treatment for people suffering from injury or disease. Physicians examine patients, obtain medical histories, and order, perform, and interpret diagnostic tests. They counsel patients on diet, hygiene, and preventive healthcare.

There are two types of physicians: M.D. (Medical Doctor) and D.O. (Doctor of Osteopathic Medicine). M.D.s also are known as allopathic physicians. While both M.D.s and D.O.s may use all accepted methods of treatment, including drugs and surgery, D.O.s place special emphasis on the body’s musculoskeletal system, preventive medicine, and holistic patient care. D.O.s are most likely to be primary care specialists although they can be found in all specialties. About half of D.O.s practice general or family medicine, general internal medicine, or general pediatrics.

Physicians work in one or more of several specialties, including, but not limited to, anesthesiology, family and general medicine, general internal medicine, general pediatrics, obstetrics and gynecology, psychiatry, and surgery.

Anesthesiologists focus on the care of surgical patients and pain relief. Like other physicians, they evaluate and treat patients and direct the efforts of their staffs. Through continual monitoring and assessment, these critical care specialists are responsible for maintenance of the patient’s vital life functions—heart rate, body temperature, blood pressure, breathing—during surgery. They also work outside of the operating room, providing pain relief in the intensive care unit, during labor and delivery, and for those who suffer from chronic pain. Anesthesiologists confer with other physicians and surgeons about appropriate treatments and procedures before, during, and after operations.

Family and general physicians often provide the first point of contact for people seeking healthcare, by acting as the traditional family physician. They assess and treat a wide range of conditions, from sinus and respiratory infections to broken bones. Family and general physician typically have a base of regular, long-term patients. These doctors refer patients with more serious conditions to specialists or other healthcare facilities for more intensive care.

General internists diagnose and provide nonsurgical treatment for a wide range of problems that affect internal organ systems, such as the stomach, kidneys, liver, and digestive tract. Internists use a variety of diagnostic techniques to treat patients through medication or hospitalization. Like general practitioners, general internists commonly act as primary care specialists. They treat patients referred from other specialists and, in turn, they refer patients to other specialists when more complex care is required.

General pediatricians care for the health of infants, children, teenagers, and young adults. They specialize in the diagnosis and treatment of a variety of ailments specific to young people and track patients’ growth to adulthood. Like most physicians, pediatricians work with different healthcare workers, such as nurses and other physicians, to assess and treat children with various ailments. Most of the work of pediatricians involves treating day-to-day illnesses—minor injuries, infectious diseases, and immunizations—that are common to children, much as a general practitioner treats adults. Some pediatricians specialize in pediatric surgery or serious medical conditions, such as autoimmune disorders or serious chronic ailments.

Obstetricians and gynecologists (OB/GYNs) specialize in women’s health. They are responsible for women’s general medical care, and they also provide care related to pregnancy and the reproductive system. Like general practitioners, OB/GYNs attempt to prevent, diagnose, and treat general health problems, but they focus on ailments specific to the female anatomy, such as cancers of the breast or cervix, urinary tract and pelvic disorders, and hormonal disorders. OB/GYNs also specialize in childbirth, which includes treating and counseling women throughout their pregnancy, from giving prenatal diagnoses to assisting with delivery and providing postpartum care.

Psychiatrists are the primary mental healthcaregivers. They assess and treat mental illnesses through a combination of psychotherapy, psychoanalysis, hospitalization, and medication. Psychotherapy involves regular discussions with patients about their problems; the psychiatrist helps them find solutions through changes in their behavioral patterns, the exploration of their past experiences, or group and family therapy sessions. Psychoanalysis involves long-term psychotherapy and counseling for patients. In many cases, medications are administered to correct chemical imbalances that cause emotional problems.

Surgeons specialize in the treatment of injury, disease, and deformity through operations. Using a variety of instruments, and with patients under anesthesia, a surgeon corrects physical deformities, repairs bone and tissue after injuries, or performs preventive surgeries on patients with debilitating diseases or disorders. Although a large number perform general surgery, many surgeons choose to specialize in a specific area. One of the most prevalent specialties is orthopedic surgery: the treatment of the musculoskeletal system. Others include neurological surgery (treatment of the brain and nervous system), cardiovascular surgery, otolaryngology (treatment of the ear, nose, and throat), and plastic or reconstructive surgery. Like other physicians, surgeons also examine patients, perform and interpret diagnostic tests, and counsel patients on preventive healthcare.

Other physicians and surgeons work in a number of other medical and surgical specialists, including allergists, cardiologists, dermatologists, emergency physicians, gastroenterologists, ophthalmologists, pathologists, and radiologists.

Work environment. Many physicians—primarily general and family practitioners, general internists, pediatricians, OB/GYNs, and psychiatrists—work in small private offices or clinics, often assisted by a small staff of nurses and other administrative personnel. Increasingly, physicians are practicing in groups or healthcare organizations that provide backup coverage and allow for more time off. Physicians in a group practice or healthcare organization often work as part of a team that coordinates care for a number of patients; they are less independent than the solo practitioners of the past. Surgeons and anesthesiologists usually work in well-lighted, sterile environments while performing surgery and often stand for long periods. Most work in hospitals or in surgical outpatient centers.

Many physicians and surgeons work long, irregular hours. In 2008, 43 percent of all physicians and surgeons worked 50 or more hours a week. Nine percent of all physicians and surgeons worked part-time. Physicians and surgeons travel between office and hospital to care for their patients. While on call, a physician will deal with many patients’ concerns over the phone and make emergency visits to hospitals or nursing homes.

Physicians examine patients, obtain medical histories, and order, perform, and interpret diagnostic tests.

Training, Other Qualifications, and Advancement

The common path to practicing as a physician requires 8 years of education beyond high school and 3 to 8 additional years of internship and residency. All States, the District of Columbia, and U.S. territories license physicians.

Education and training. Formal education and training requirements for physicians are among the most demanding of any occupation—4 years of undergraduate school, 4 years of medical school, and 3 to 8 years of internship and residency, depending on the specialty selected. A few medical schools offer combined undergraduate and medical school programs that last 6 or 7 years rather than the customary 8 years.

Premedical students must complete undergraduate work in physics, biology, mathematics, English, and inorganic and organic chemistry. Students also take courses in the humanities and the social sciences. Some students volunteer at local hospitals or clinics to gain practical experience in the health professions.

The minimum educational requirement for entry into medical school is 3 years of college; most applicants, however, have at least a bachelor’s degree, and many have advanced degrees. In 2008, there were 129 medical schools accredited by the Liaison Committee on Medical Education (LCME). The LCME is the national accrediting body for M.D. medical education programs. The American Osteopathic Association accredits schools that award a D.O. degree; there were 25 schools accredited in 31 locations in 2008.

Acceptance to medical school is highly competitive. Most applicants must submit transcripts, scores from the Medical College Admission Test, and letters of recommendation. Schools also consider an applicant’s character, personality, leadership qualities, and participation in extracurricular activities. Most schools require an interview with members of the admissions committee.

Students spend most of the first 2 years of medical school in laboratories and classrooms, taking courses such as anatomy, biochemistry, physiology, pharmacology, psychology, microbiology, pathology, medical ethics, and laws governing medicine. They also learn to take medical histories, examine patients, and diagnose illnesses. During their last 2 years, students work with patients under the supervision of experienced physicians in hospitals and clinics, learning acute, chronic, preventive, and rehabilitative care. Through rotations in internal medicine, family practice, obstetrics and gynecology, pediatrics, psychiatry, and surgery, they gain experience in the diagnosis and treatment of illness.

Following medical school, almost all M.D.s enter a residency—graduate medical education in a specialty that takes the form of paid on-the-job training, usually in a hospital. Most D.O.s serve a 12-month rotating internship after graduation and before entering a residency, which may last 2 to 6 years.

A physician’s training is costly. According to the Association of American Medical Colleges, in 2007 85 percent of public medical school graduates and 86 percent of private medical school graduates were in debt for educational expenses.

Licensure and certification. To practice medicine as a physician, all States, the District of Columbia, and U.S. territories require licensing. All physicians and surgeons practicing in the United States must pass the United States Medical Licensing Examination (USMLE). To be eligible to take the USMLE in its entirety, physicians must graduate from an accredited medical school. Although physicians licensed in one State usually can get a license to practice in another without further examination, some States limit reciprocity. Graduates of foreign medical schools generally can qualify for licensure after passing an examination and completing a U.S. residency. For specific information on licensing in a given State, contact that State’s medical board.

M.D.s and D.O.s seeking board certification in a specialty may spend up to 7 years in residency training, depending on the specialty. A final examination immediately after residency or after 1 or 2 years of practice is also necessary for certification by a member board of the American Board of Medical Specialists (ABMS) or the American Osteopathic Association (AOA). The ABMS represents 24 boards related to medical specialties ranging from allergy and immunology to urology. The AOA has approved 18 specialty boards, ranging from anesthesiology to surgery. For certification in a subspecialty, physicians usually need another 1 to 2 years of residency.

Other qualifications. People who wish to become physicians must have a desire to serve patients, be self-motivated, and be able to survive the pressures and long hours of medical education and practice. Physicians also must have a good bedside manner, emotional stability, and the ability to make decisions in emergencies. Prospective physicians must be willing to study throughout their career to keep up with medical advances.

Advancement. Some physicians and surgeons advance by gaining expertise in specialties and subspecialties and by developing a reputation for excellence among their peers and patients. Physicians and surgeons may also start their own practice or join a group practice. Others teach residents and other new doctors, and some advance to supervisory and managerial roles in hospitals, clinics, and other settings.

Employment

Physicians and surgeons held about 661,400 jobs in 2008; approximately 12 percent were self-employed. About 53 percent of wage–and-salary physicians and surgeons worked in offices of physicians, and 19 percent were employed by hospitals. Others practiced in Federal, State, and local governments, educational services, and outpatient care centers.

According to 2007 data from the American Medical Association (AMA), 32 percent of physicians in patient care were in primary care, but not in a subspecialty of primary care. (See table 1.)

A growing number of physicians are partners or wage-and-salary employees of group practices. Organized as clinics or as associations of physicians, medical groups can more easily afford expensive medical equipment, share support staff, and benefit from other business advantages.

According to the AMA, the New England and Middle Atlantic States have the highest ratios of physicians to population; the South Central and Mountain States have the lowest. Physicians tend to locate in urban areas, close to hospitals and education centers. AMA data showed that in 2007, about 75 percent of physicians in patient care were located in metropolitan areas while the remaining 25 percent were located in rural areas.

Job Outlook

Employment is expected to grow much faster than the average for all occupations. Job opportunities should be very good, particularly in rural and low-income areas.

Employment change. Employment of physicians and surgeons is projected to grow 22 percent from 2008 to 2018, much faster than the average for all occupations. Job growth will occur because of continued expansion of healthcare-related industries. The growing and aging population will drive overall growth in the demand for physician services, as consumers continue to demand high levels of care using the latest technologies, diagnostic tests, and therapies. Many medical schools are increasing their enrollments based on perceived new demand for physicians.

Despite growing demand for physicians and surgeons, some factors will temper growth. For example, new technologies allow physicians to be more productive. This means physicians can diagnose and treat more patients in the same amount of time. The rising cost of healthcare can dramatically affect demand for physicians’ services. Physician assistants and nurse practitioners, who can perform many of the routine duties of physicians at a fraction of the cost, may be increasingly used. Furthermore, demand for physicians’ services is highly sensitive to changes in healthcare reimbursement policies. If changes to health coverage result in higher out-of-pocket costs for consumers, they may demand fewer physician services.

Job prospects. Opportunities for individuals interested in becoming physicians and surgeons are expected to be very good. In addition to job openings from employment growth, openings will result from the need to replace the relatively high number of physicians and surgeons expected to retire over the 2008-18 decade.

Job prospects should be particularly good for physicians willing to practice in rural and low-income areas because these medically underserved areas typically have difficulty attracting these workers. Job prospects will also be especially good for physicians in specialties that afflict the rapidly growing elderly population. Examples of such specialties are cardiology and radiology because the risks for heart disease and cancer increase as people age.

Projections Data

Earnings

Earnings of physicians and surgeons are among the highest of any occupation. According to the Medical Group Management Association’s Physician Compensation and Production Survey, median total compensation for physicians varied by their type of practice. In 2008, physicians practicing primary care had total median annual compensation of $186,044, and physicians practicing in medical specialties earned total median annual compensation of $339,738.

Self-employed physicians—those who own or are part owners of their medical practice—generally have higher median incomes than salaried physicians. Earnings vary according to number of years in practice, geographic region, hours worked, skill, personality, and professional reputation. Self-employed physicians and surgeons must provide for their own health insurance and retirement.

Related Occupations

Physicians work to prevent, diagnose, and treat diseases, disorders, and injuries. Other healthcare practitioners who need similar skills and who exercise critical judgment include:

Chiropractors

Dentists

Optometrists

Physician assistants

Podiatrists

Registered nurses

Veterinarians

Sources of Additional Information

For a list of medical schools and residency programs, as well as general information on premedical education, financial aid, and medicine as a career contact:

• Association of American Medical Colleges, Section for Student Services, 2450 N St. NW., Washington, DC 20037. Internet: http://www.aamc.org/students

For information on licensing, contact:

• Federation of State Medical Boards, P.O. Box 619850 Dallas, TX 75261-9850. Internet: http://www.fsmb.org

For general information on physicians, contact:

• American Medical Association, 515 N. State St., Chicago, IL 60654. Internet: http://www.ama-assn.org/go/becominganmd
• American Osteopathic Association, Department of Communications, 142 East Ontario St., Chicago, IL 60611. Internet: http://www.osteopathic.org

For information about various medical specialties, contact:

• American Academy of Family Physicians, Resident Student Activities Department, P.O. Box 11210, Shawnee Mission, KS 66207-1210. Internet: http://fmignet.aafp.org
• American Board of Medical Specialties, 222 N. LaSalle St., Suite 1500, Chicago, IL 60601. Internet:http://www.abms.org
• American College of Obstetricians and Gynecologists, P.O. Box 96920, Washington, DC 20090. Internet:http://www.acog.org
• American College of Surgeons, Division of Education, 633 North Saint Clair St., Chicago, IL 60611. Internet:http://www.facs.org
• American Psychiatric Association, 1000 Wilson Blvd., Suite 1825, Arlington, VA 22209. Internet:http://www.psych.org
• American Society of Anesthesiologists, 520 N. Northwest Hwy., Park Ridge, IL 60068. Internet:http://www.asahq.org/career/homepage.htm

Information on Federal scholarships and loans is available from the directors of student financial aid at schools of medicine. Information on licensing is available from State boards of examiners.

Source: United States Department of Labor, Bureau of Labor Statistics – http://www.bls.gov/oco/ocos074.htm

Sonography, or ultrasonography, is the use of sound waves to generate an image for the assessment and diagnosis of various medical conditions. Sonography is commonly associated with obstetrics and the use of ultrasound imaging during pregnancy, but this technology has many other applications in the diagnosis and treatment of medical conditions throughout the body.

Diagnostic medical sonographers use special equipment to direct high frequency sound waves into areas of the patient’s body. Sonographers operate the equipment, which collects reflected echoes and forms an image that may be videotaped, transmitted, or photographed for interpretation and diagnosis by a physician.

Sonographers begin by explaining the procedure to the patient and recording any medical history that may be relevant to the condition being viewed. They then select appropriate equipment settings and direct the patient to move into positions that will provide the best view. To perform the exam, sonographers use a transducer, which transmits sound waves in a cone-shaped or rectangle-shaped beam. Although techniques vary by the area being examined, sonographers usually spread a special gel on the skin to aid the transmission of sound waves.

Viewing the screen during the scan, sonographers look for subtle visual cues that contrast healthy areas with unhealthy ones. They decide whether the images are satisfactory for diagnostic purposes and select which ones to store and show to the physician. Sonographers take measurements, calculate values, and analyze the results in preliminary findings for the physicians.

In addition to working directly with patients, diagnostic medical sonographers keep patient records and adjust and maintain equipment. They also may prepare work schedules, evaluate equipment purchases, or manage a sonography or diagnostic imaging department.

Diagnostic medical sonographers may specialize in obstetric and gynecologic sonography (images of the female reproductive system), abdominal sonography (images of the liver, kidneys, gallbladder, spleen, and pancreas), neurosonography (images of the brain and other parts of the nervous system), or breast sonography. In addition, sonographers may specialize in vascular sonography or cardiac sonography. (Vascular sonographers and cardiac sonographers are covered in the Handbook statement on cardiovascular technologists and technicians.)

Obstetric and gynecologic sonographers specialize in the imaging of the female reproductive system. Included in the discipline is one of the more well-known uses of sonography: examining the fetus of a pregnant woman to track the baby’s growth and health.

Abdominal sonographers inspect a patient’s abdominal cavity to help diagnose and treat conditions primarily involving the gallbladder, bile ducts, kidneys, liver, pancreas, spleen, and male reproductive system. Abdominal sonographers also are able to scan parts of the chest, although studies of the heart using sonography usually are done by echocardiographers.

Neurosonographers focus on the nervous system, including the brain. In neonatal care, neurosonographers study and diagnose neurological and nervous system disorders in premature infants. Like other sonographers, neurosonographers operate transducers to perform the sonogram, but they use frequencies and beam shapes different from those used by obstetric and abdominal sonographers.

Breast sonographers use sonography to study diseases of the breasts. Sonography aids mammography in the detection of breast cancer. Breast sonography also is used to track tumors, monitor blood supply conditions, and assist in the accurate biopsy of breast tissue. Breast sonographers use high-frequency transducers made exclusively to study breast tissue.

Work environment. Sonographers typically work in healthcare facilities that are clean. They usually work at diagnostic imaging machines in darkened rooms, but they also may perform procedures at patients’ bedsides. Sonographers may be on their feet for long periods of time and may have to lift or turn disabled patients.

Some sonographers work as contract employees and may travel to several healthcare facilities in an area. Similarly, some sonographers work with mobile imaging service providers and travel to patients and use mobile diagnostic imaging equipment to provide service in areas that otherwise would not have access to such services.

Most full-time sonographers work about 40 hours a week. Some sonographers work overtime. Also, sonographers may have evening and weekend hours when they are on call and must be ready to report to work on short notice.

Diagnostic medical sonographers usually use diagnostic imaging machines in dark rooms, but may also perform procedures at a patient’s bedside.

Training, Other Qualifications, and Advancement

Diagnostic medical sonography is an occupation to which there are multiple paths of entry. Formal education in sonography, training, or a combination of these are accepted by employers. Employers do prefer sonographers who have received education from an accredited program or completed training in an accredited practice, and who are registered.

Education and training. There are several avenues for entry into the field of diagnostic medical sonography. Sonographers may train in hospitals, vocational-technical institutions, colleges or universities, or the Armed Forces. Some training programs prefer applicants with experience in other healthcare professions or high school graduates with courses in mathematics, health, and science.

Colleges and universities offer formal training in both 2-year and 4-year programs, resulting in either an associate or a bachelor’s degree. Two-year programs are the most prevalent. Coursework includes classes in anatomy, physiology, instrumentation, basic physics, patient care, and medical ethics. In 2008, the Commission on Accreditation of Allied Health Education Programs (CAAHEP) accredited over 150 training programs. Accredited programs are offered by colleges and universities. Some hospital programs are accredited as well.

A few 1-year programs that typically result in a vocational certificate also are accepted as proper education by employers. These programs are useful usually only for workers already employed in a healthcare occupation who seek to increase their marketability by training in sonography. One-year vocational-certificate programs are not accredited by the CAAHEP.

Certification and other qualifications. No States require licensure in diagnostic medical sonography. However, sonographers may become credentialed by one of the professional certifying bodies. Most employers prefer to hire registered sonographers because registration provides an objective measure of an individual’s professional standing. To become registered, one must first become eligible to take the examination by completing the proper education, training, or work experience. The exam typically includes a physics and instrumentation exam in a sonography specialty. Typically, sonographers must complete a required number of continuing-education hours to maintain registration. For specific details on credentialing, contact the certifying organization.

The American Registry for Diagnostic Medical Sonography (ARDMS) certifies each person who passes the exam as a Registered Diagnostic Medical Sonographer (RDMS). This credential can be obtained for several different specialty areas like the abdomen, breast, or nervous system. The ARDMS also credentials cardiac and vascular sonographers. The American Registry of Radiologic Technologist offers credentials in breast and vascular sonography. The Cardiovascular Credentialing International credentials cardiac sonographers. (Vascular sonographers and cardiac sonographers are covered in the Handbook statement on cardiovascular technologists and technicians.)

Sonographers should have good communication and interpersonal skills, because they must be able to explain technical procedures and results to their patients, some of whom may be nervous. Good hand-eye coordination is particularly important to obtaining quality images. It is very important that sonographers enjoy lifelong learning, because continuing education is crucial to workers in the ever-changing field of diagnostic medicine.

Advancement. Sonographers can seek advancement by obtaining competency in more than one specialty. For example, obstetric sonographers might seek training in abdominal sonography to broaden their opportunities and increase their marketability. Sonographers also may seek multiple credentials—for example, being both a registered diagnostic medical sonographer and a registered diagnostic cardiac sonographer.

Sonographers may advance by taking supervisory, managerial, or administrative positions.

Employment

Diagnostic medical sonographers held about 50,300 jobs in 2008. About 59 percent of all sonographer jobs were in public and private hospitals. The remaining jobs were typically in offices of physicians, medical and diagnostic laboratories, and outpatient care centers.

Job Outlook

Faster than average employment growth is expected. Job opportunities should be favorable.

Employment change. Employment of diagnostic medical sonographers is expected to increase by about 18 percent through 2018—faster than the average for all occupations. As the population continues to age, there will be an increasing demand for diagnostic imaging. Additional job growth is expected as healthcare providers increasingly utilize ultrasound imaging as a safer and more cost-effective alternative to radiological procedures. Ultrasound imaging technology is expected to evolve rapidly and spawn many new sonography procedures, enabling sonographers to scan and image areas of the body where ultrasound has not traditionally been used.

Hospitals will remain the principal employer of diagnostic medical sonographers. However, employment is expected to grow more rapidly in offices of physicians and in medical and diagnostic laboratories. Health care facilities such as these are expected to increase in number because of the strong shift toward outpatient care, encouraged by third-party payers and made possible by technological advances and less expensive ultrasound equipment that permit more procedures to be performed outside of hospitals.

Job prospects. Job opportunities should be favorable. In addition to job openings from growth, some openings will arise from the need to replace sonographers who retire or leave the occupation permanently. However, job opportunities will vary by geographic area. Sonographers willing to relocate will have the best job opportunities. Sonographers with multiple specialties or multiple credentials also will have good prospects.

Projections Data

Projections data from the National Employment Matrix

Earnings

The median annual wage of diagnostic medical sonographers was $61,980 in May 2008. The middle 50 percent of sonographers earned wages between $52,570 and $73,680 a year. The lowest 10 percent earned less than $43,600, and the highest 10 percent earned more than $83,950. Median annual wages of diagnostic medical sonographers in May 2008 were $62,340 in offices of physicians and $61,870 in general medical and surgical hospitals.

Related Occupations

Health care occupations with similar diagnostic and treatment responsibilities include:

Cardiovascular technologists and technicians

Clinical laboratory technologists and technicians

Nuclear medicine technologists

Radiologic technologists and technicians

Sources of Additional Information

For information on a career as a diagnostic medical sonographer, contact:

• Society of Diagnostic Medical Sonography, 2745 Dallas Pkwy., Suite 350, Plano, TX 75093-8730. Internet: http://www.sdms.org

For information on becoming a registered diagnostic medical sonographer, contact:

• American Registry for Diagnostic Medical Sonography, 51 Monroe St., Plaza East One, Rockville, MD 20850-2400. Internet: http://www.ardms.org

For certification information, contact:

• American Registry of Radiologic Technologists, 1255 Northland Dr., St. Paul, MN 55120-1155. Internet: http://www.arrt.org

For more information on ultrasound in medicine and accredited practices, contact:

• American Institute of Ultrasound in Medicine, 14750 Sweitzer Lane, Suite 100, Laurel, MD 20707. Internet: http://www.aium.org

For a current list of accredited education programs in diagnostic medical sonography, contact:

• Joint Review Committee on Education in Diagnostic Medical Sonography, 2025 Woodlane Dr., St. Paul, MN 55125-2998. Internet: http://www.jrcdms.org
• Commission on Accreditation of Allied Health Education Programs, 1361 Park St., Clearwater, FL 33756. Internet: http://www.caahep.org

Source: United States Department of Labor, Bureau of Labor Statistics –  http://www.bls.gov/oco/ocos273.htm

Various factors effect the success rate of tubal reversals, however for healthy young women the rate can be higher than 90%.^[1]

Tubal anatomy

Fallopian Tube Anatomy

To understand the techniques of tubal reversal surgery, it is helpful to visualize the anatomy of the normal fallopian tube^[2]. The fallopian tube is a muscular organ extending from the uterus and ending next to the ovary. The tube is attached to the ovary by a small ligament. The inner tubal lining is rich in cilia. These are microscopic hair-like projections that beat in waves that help move the egg or ovum to the uterus in conjunction with muscular contractions of the tube.

The fallopian tube is normally about 10 cm (4 inches) long and consists of several segments. Starting from the uterus and proceeding outward, these are the:

• Interstitial segment – extends from the uterine cavity through the uterine muscle
• Isthmic segment – narrow muscular portion adjacent to the uterus
• Ampullary segment – wider and longer middle part of the tube
• Infundibular segment – funnel shaped segment next to the fimbrial end
• Fimbrial segment – wide opening at the end of the tube facing the ovary

Tubal reversal procedures

Microsurgery

Tubal ligation reversal utilizes the techniques of microsurgery to open and reconnect the fallopian tube segments that remain after a tubal sterilization procedure. Microsurgery minimizes tissue damage and bleeding during surgery. Essential elements of microsurgical technique include gentle tissue handling, magnifying the operating field, keeping body tissues in their normal state with warmed irrigation fluids, and using the smallest sutures with the thinnest needles capable of holding the tubal ends together to promote proper healing of the rejoined tubal segments.

Tubotubal anastomosis

Following a tubal ligation, there are usually two remaining fallopian tube segments – the proximal tubal segment that emerges from the uterusand the distal tubal segment that ends with the fimbria next to the ovary. After opening the blocked ends of the remaining tubal segments, a narrow flexible stent is gently threaded through their inner cavities or lumens and into the uterine cavity. This ensures that the fallopian tube is open from the uterine cavity to its fimbrial end. The newly created tubal openings are then drawn next to each other by placing a retention suture in the connective tissue that lies beneath the fallopian tubes (mesosalpinx). The retention suture avoids the likelihood of the tubal segments subsequently pulling apart. Microsurgical sutures are used to precisely align the muscular portion (muscularis externa) and outer layer (serosa), while avoiding the inner layer (mucosa) of the fallopian tube. The tubal stent is then gently withdrawn from the fimbrial end of the tube.

Tubouterine implantation

In a small percentage of cases, a tubal ligation procedure leaves only the distal portion of the fallopian tube and no proximal tubal segment. This may occur when monopolar tubal coagulation has been applied to the isthmic segment of the fallopian tube as it emerges from the uterus. In this situation, a new opening can be created through the uterine muscle and the remaining tubal segment inserted into the uterine cavity. This microsurgical procedure is called tubouterine implantation, uterotubal implantation, or, simply, tubal implantation. Tubal implantation is performed when tubal anastomosis is not possible due to the absence of a proximal tubal segment and interstitial tubal lumen.

Ampullary salpingostomy

Fimbriectomy is an uncommon type of tubal ligation that is performed by removing the fimbrial portion of the fallopian tube next to the ovary, leaving the tubal segment attached to the uterus. After fimbriectomy, the remaining tubal segment can be opened by the technique ampullary salpingostomy^[3]. A microsurgical electrode is used to open the tubal end and expose the internal lining. When the opening has been enlarged sufficiently and the internal lining or endothelium has extruded from the tubal end, sutures are placed to keep the endothelium folded outward over the edge and to prevent the tube from closing again.

Mini-laparotomy tubal reversal

Mini-laparotomy for tubal reversal surgery involves making a small incision in the abdominal wall just above the pubic bone after shaving the hair with a sterile hair clipper. The size and location of the incision as well as the plastic surgery techniques used to close it make the hair-line scar invisible when it has healed. Atraumatic surgical techniques involve the use of local anesthesia at the incision site and other tissues operated upon. This makes the surgery comfortable and minimizes post-operative pain. As opposed to standard operative methods, avoiding the use of surgical retractors and packs, constantly irrigating tissues to keep them moist and at body temperature, and operating under magnification throughout the procedure results in very rapid patient recovery. Operating with microsurgical instruments allows precision in suturing of the tubal segments than is possible with longer needle holders and other instruments such as are used in laparoscopic surgery. In the experience of a tubal reversal doctor who has performed more than 8000 outpatient reversal procedures, this is the preferred method of minimally invasive surgery for tubal ligation reversal. After the mini-laparotomy approach, patients may attempt to become pregnant as soon as they are fully recovered from their surgery.

Laparoscopic tubal reversal

Laparoscopic Tubal Reversal is a minimally-invasive surgical procedure (laparoscopy), using small, specially-designed instruments to repair and reconnect the fallopian tubes.

After general anesthesia has been administered, a 10mm (less than ½-inch) tube (trocar)is inserted just at the lower edge of the navel, and a special gas is pumped into the abdomen to create enough space to perform the operation safely and precisely. The laparoscope (a telescope), attached to a camera, is brought into the abdomen through the same tube, and the pelvis and abdomen are thoroughly inspected. The tubes are evaluated and the obstruction (ligation, burn, ring, or clip) is examined. Three small instruments (5mm each, less than ¼-inch) are used to remove the occlusion and prepare the two segments of the tube to be reconnected.

One technique involves the use of a tubal cannulator, which is inserted into the uterus through the cervix, allowing the tube to be threaded with a fine stent. This allows for improved alignment of the tubes, so a much better connection can be accomplished.^[4] Tiny sutures (less than a hair in thickness) are carefully and meticulously placed to connect the two segments.

Once the connection (anastomosis) is completed, a blue dye is injected through the cervix, traveling through the uterus and tubes, all the way to the abdomen. This is to make sure the tubes have been aligned properly and that the connection is working well.

All instruments are removed, the gas is extracted from the abdomen, and the patient is awakened and taken to the recovery room to be watched and cared for by the nurses, as well as by the anesthesiologist who makes sure the patient is comfortable and without pain. On the average, two to four hours later most patients are ready to be discharged.

Patients are seen between 5–7 days after the operation to look at the small incisions and remove any stitches if necessary. Most of the time, the few stitches that were placed will be under the skin and will be absorbed by the body, without need for removal.

Patients should wait two to three months prior to attempting pregnancy in order to give the tubes a chance to heal completely. Trying to conceive before could result in an increased risk of ectopic pregnancy (pregnancy inside the fallopian tube instead of in the uterus).

When performed by a trained laparoscopic or outpatient tubal reversal surgeon, laparoscopic tubal reversal combines the success rates of micro-surgical techniques with the advantages of minimally-invasive surgery – namely faster recovery, better healing, less pain, fewer complications, and no large disfiguring scars.^[5]

Robotic assisted tubal reversal

Robotic assisted tubal reversal surgery is a surgical procedure in which the fallopian tubes are repaired by a surgeon using a remotely controlled, robotic surgical system.

The robotic system involves two components: a patient side-cart (also referred to as the robot) and a surgeon’s console. The robot is placed adjacent to the patient and has several attached arms. Each arm has a unique surgical instrument and performs a specialized surgical function. The surgeon sits near the patient at the surgeon’s console and visualizes the surgery through a monitor. The surgeon performs the entire reversal surgery using controllers located inside the surgeon’s console.

Robotic surgery experts have suggested robotic tubal ligation reversal offers the advantage of smaller incisions when compared to traditional laparotomy tubal reversal surgery. These smaller incisions have been reported to result in less pain and quicker return to work after robotic tubal reversal when compared to traditional tubal ligation reversal using larger abdominal incisions. Robotic experts have also suggested the robotic system offers a greater range of motion and more surgical dexterity than a surgeon can obtain during laparoscopic tubal ligation reversal. The potential disadvantages to robotic surgery are longer operating times and higher costs.

A retrospective, Cleveland Clinic study compared 26 patients who underwent robotic assisted tubal reversal to 41 patients who underwent outpatient mini-lapraotomy (abdominal incision) tubal reversal. Robotic tubal reversal patients, when compared to abdominal tubal reversal surgery patients, had longer times under anesthesia (283 minutes vs 205 minutes) and longer times in surgery (229 minutes vs 181 minutes). On average, robotic tubal reversal patients returned to work one week sooner than abdominal tubal reversal patients and the robotic tubal reversal surgeries were also more expensive than abdominal tubal reversal surgeries^[6].

An Ohio State University study evaluating robotic tubal reversal vs abdominal tubal reversal discovered similar findings but also evaluated pregnancy outcomes. Robotic tubal reversal surgery, when compared to abdominal tubal reversal surgery, had longer operative times (201 minutes vs 155 minutes), shorter hospital stays (4 hours compared to 34 hours), and quicker return to activities of daily living. Pregnancy outcomes of robotic tubal reversal surgery patients were also compared to pregnancy outcome of abdominal incision tubal reversal patients. Approximately 65% of the robotic tubal reversal surgery patients became pregnant compared with 50% of the abdominal incision patients. Of the pregnancies abnormal pregnancies 6 were in the robotic tubal reversal patients (4 ectopic and 2 miscarriage) and 2 were in the abdominal incision patients (1 ectopic and 1 miscarriage). Both surgeries were expensive and were found to cost in excess of $92, 000. Robotic tubal reversal surgery was slightly more costly than the abdominal incision tubal reversal^[7].

Surgeons who specialize in outpatient, abdominal mini-incision tubal reversal can offer a more affordable tubal reversal with pregnancy rates as high as 80% when compared to robotic tubal reversal surgery. Using mini-abdominal incisions during an outpatient reversal, these same specialists can offer abdominal incision reversal patients as quick a return to activities of daily living and work as do providers of both laparoscopic tubal reversal and robotic assisted tubal reversal^[8].

Essure sterilization reversal

Essure sterilization is a hysteroscopic tubal occlusion procedure and was approved by the FDA in 2002. Essure sterilization can be done as a simple, outpatient procedure. The Essure procedure requires a small camera (hysteroscope) be inserted through the cervix and into the uterine cavity. Two small, metallic coils are then inserted into each tubal ostia and into the isthmic portion of the fallopian tube. The coils cause the isthmic portion of the fallopian tube to scar (or heal) closed. To confirm tubal closure, a HSG x-ray should be performed three months after the Essure procedure. If either fallopian tube is open after the Essure procedure, then the Essure procedure should be repeated or another type of tubal occlusion method should be performed.

Essure sterilization can be reversed and does not have to be permanent. Reversal of Essure sterilization requires the blocked isthmic portion of the tube be bypassed. The procedure to bypass the blocked portion of the tube is called a tubouterine implantation.

Tubouterine implantation requires the reversal surgeon to make an incision into the uterus and reinsert the healthy portion of the tube through the uterine muscle and into the uterine cavity. Experts who specialize in tubal reversal surgery and tubouterine implantation are able to perform this type of reversal as an outpatient procedure and provide success rates comparable, if not better, than IVF pregnancy success rates^[9].

Adiana sterilization reversal

Adiana sterilization was approved by the FDA in 2009. Adiana sterilization is a hysteroscopic tubal occlusion procedure, which is very similar to Essure sterilization. The Adiana procedure is a outpatient procedure performed by inserting a small camera (hysteroscope) through the cervix and into the uterine cavity. A smaller catheter is inserted into the tubal ostia. The catheter emits radiowaves (microwaves). The radiowaves cause injury to the tubal lining and will result in the tube gradually healing closed. Prior to removal of the catheter a small silicone stent is left inside the isthmic portion of the tube and this promotes tubal closure by the acceleration of the tubal scarring. To confirm tubal closure, a HSG x-ray should be performed three months after the Adiana procedure. If either fallopian tube is open, then the Adiana procedure should be redone or another type of tubal occlusion method should be performed.

Adiana sterilization can be reversed and does not have to be permanent. Reversal of Adiana is similar to reversal of Essure sterilization and requires the blocked isthmic portion of the tube be bypassed. The procedure to bypass the blocked portion of the tube is called a tubouterine implantation.

Tubouterine implantation requires the reversal surgeon to make an incision into the uterus and reinsert the healthy portion of the tube through the uterine muscle and into the uterine cavity. Experts who specialize in tubal reversal surgery and tubouterine implantation are able to perform this type of reversal as an outpatient procedure and provide success rates comparable, if not better, than IVF pregnancy success rates^[10]. The first successful Adiana reversal has recently been described^[11].

Reasons for tubal reversal

Women give many reasons for having a tubal ligation reversal. One of the questions that Dr. Berger asks his patients is “What made you decide to have a tubal reversal procedure at this time?” The most common responses to this question are:

• Remarriage with desire to have children with new spouse (75%)
• Same marriage with desire to have more children (20%)
• Death of a child (2%)
• Relief of symptoms of “Post Tubal Ligation Syndrome” (2%)
• Religious or spiritual concerns (1%)

Sterilization regret

In a study called the U.S. Collaborative Review of Sterilization (CREST) , women who had tubal ligations were asked “Do you still think tubal sterilization as a permanent method of birth control was a good choice for you?” Overall, 13% of women said they did not think that the tubal ligation was a good choice. The percentage expressing regret was 20% for women aged 30 years or younger at the time of sterilization, compared with 6% for women older than 30 years at the time of tubal ligation. For women under age 25, the rate was 40%. (Pointing out that this study does not seem to make a difference between women who were mothers at the time of sterilization and those who were childless by choice. One would assume that mothers who thought they would not want to have more children are more likely to change their minds later rather than those who have never felt the need to have children.)

Despite the high percentage of women who subsequently regret having had a tubal ligation, only 0.2% of women in the CREST study underwent tubal reversal. Reasons for this discrepancy may include lack of information about tubal reversal, cost of the procedure, and lack of insurance coverage for this procedure. Women often receive inaccurate information about tubal reversal – such as tubal ligation cannot be reversed, or the only treatment option is in vitro fertilization (IVF), or tubal reversal is available only as a high cost operation requiring hospitalization.

Pregnancy Statistics

Pregnancy statistics for tubal reversal vary widely depending upon many factors. These include the patient population (women’s ages, methods of tubal ligation that they had performed, experience of the surgeon and techniques for repairing the tubes, length of follow-up after reversal surgery and other factors). The following data are from the Tubal Reversal Pregnancy Report 2009, the largest study ever conducted. The study included 5,046 patients over an 8 year period following tubal reversal surgery performed at Chapel Hill Tubal Reversal Center, Chapel Hill, NC.

Pregnancy Rates By Age

As expected, younger women had higher pregnancy rates than older women. The pregnancy rate after surgery ranged from 80% for women under 30 to 31% for women 40 years of age and older (Table 1).^[12]

Pregnancy Rates By Tubal Ligation Method

Reversal of tubal clip procedures had the highest pregnancy rate (75%), followed by tubal rings (72%), coagulation (66%) and ligation/resection (63%)as shown in Table 2.

Pregnancy Rates By Age And Method

Pregnancy rates taking into account both age and tubal ligation method are shown in Table 3. The highest pregnancy rate (90%) was reported by women under 30 years of age who had reversal of a previous clip method of sterilization. Of the two variables, age is more predictive than tubal ligation method regarding the likelihood of becoming pregnant after reversal surgery.

Pregnancy Outcomes

Pregnancy Outcomes By Age

Table 4 shows the relationship between age and pregnancy outcome following tubal ligation reversal at Chapel Hill Tubal Reversal Center.Berger G., Tubal Reversal Pregnancy Report 2009, http://press.tubal-reversal.net/2009/tubal-reversal-pregnancy-report-2009-pregnancy_outcomes.html With increasing age, the percentage of pregnancies resulting in births declined due to an increasing percentage of miscarriages. Among women under age 35, over half of pregnancies resulted in birth or ongoing pregnancy while one third miscarried. The birth rate declined and the miscarriage rate increased significantly for women ages 40 and older. The overall ectopic pregnancy rate for all patients (14%) was higher than that found in the general population of women who have not had a tubal ligation, which is approximately 2.5%. The ectopic pregnancy rate after tubal reversal surgery may be overestimated, since some early pregnancy losses were reported as ectopic pregnancies when serum HCG levels did not rise normally but without confirmation of the diagnosis by ultrasound or laparoscopy. In the case of very early pregnancy loss, the actual site of the pregnancy (uterine or ectopic) is unknown. Whether there is an increased risk of miscarriage associated with tubal reversal is unclear. The miscarriage rate reported in the general population ranges from approximately 20% to 50% depending on a woman’s age and how early pregnancy testing is performed.

Pregnancy Outcomes By Tubal Ligation Method

Table 5 shows the relationship between the tubal ligation method and pregnancy outcomes. Tubal ligation reversal after tubal clips (Hulka clip, Filshie clip) has the best outcome of all tubal ligation methods, with the highest birth rate (69%) and lowest miscarriage rate (25%) and ectopic pregnancy rate (6%). Reversal of tubal rings (Falope ring, Yoon ring) has the second best outcome, followed in order by ligation/resection and coagulation. These findings are almost certainly related to the minimal damage to the fallopian tube caused by tubal clips and rings.

Source: http://en.wikipedia.org/wiki/Tubal_reversal

First Trimester (Week 1-Week 12)

First Trimester

During the first trimester your body undergoes many changes. Hormonal changes affect almost every organ system in your body. These changes can trigger symptoms even in the very first weeks of pregnancy. Your period stopping is a clear sign that you are pregnant. Other changes may include:

• Extreme tiredness
• Tender, swollen breasts. Your nipples might also stick out.
• Upset stomach with or without throwing up (morning sickness)
• Cravings or distaste for certain foods
• Mood swings
• Constipation (trouble having bowel movements)
• Need to pass urine more often
• Headache
• Heartburn
• Weight gain or loss

As your body changes, you might need to make changes to your daily routine, such as going to bed earlier or eating frequent, small meals. Fortunately, most of these discomforts will go away as your pregnancy progresses. And some women might not feel any discomfort at all! If you have been pregnant before, you might feel differently this time around. Just as each woman is different, so is each pregnancy.

Second Trimester (Week 13-Week 28)

Second Trimester

Most women find the second trimester of pregnancy easier than the first. But it is just as important to stay informed about your pregnancy during these months.

You might notice that symptoms like nausea and fatigue are going away. But other new, more noticeable changes to your body are now happening. Your abdomen will expand as the baby continues to grow. And before this trimester is over, you will feel your baby beginning to move!

As your body changes to make room for your growing baby, you may have:

• Body aches, such as back, abdomen, groin, or thigh pain
• Stretch marks on your abdomen, breasts, thighs, or buttocks
• Darkening of the skin around your nipples
• A line on the skin running from belly button to pubic hairline
• Patches of darker skin, usually over the cheeks, forehead, nose, or upper lip. Patches often match on both sides of the face. This is sometimes called the mask of pregnancy.
• Numb or tingling hands, called carpal tunnel syndrome
• Itching on the abdomen, palms, and soles of the feet. (Call your doctor if you have nausea, loss of appetite, vomiting, jaundice or fatigue combined with itching. These can be signs of a serious liver problem.)
• Swelling of the ankles, fingers, and face. (If you notice any sudden or extreme swelling or if you gain a lot of weight really quickly, call your doctor right away. This could be a sign ofpreeclampsia.)

Third Trimester (Week 29-Week 40)

Third Trimester

You’re in the home stretch! Some of the same discomforts you had in your second trimester will continue. Plus, many women find breathing difficult and notice they have to go to the bathroom even more often. This is because the baby is getting bigger and it is putting more pressure on your organs. Don’t worry, your baby is fine and these problems will lessen once you give birth.

Some new body changes you might notice in the third trimester include:

• Shortness of breath
• Heartburn
• Swelling of the ankles, fingers, and face. (If you notice any sudden or extreme swelling or if you gain a lot of weight really quickly, call your doctor right away. This could be a sign ofpreeclampsia.)
• Hemorrhoids
• Tender breasts, which may leak a watery pre-milk called colostrum (kuh-LOSS-struhm)
• Your belly button may stick out
• Trouble sleeping
• The baby “dropping”, or moving lower in your abdomen
• Contractions, which can be a sign of real or false labor

As you near your due date, your cervix becomes thinner and softer (called effacing). This is a normal, natural process that helps the birth canal (vagina) to open during the birthing process. Your doctor will check your progress with a vaginal exam as you near your due date. Get excited — the final countdown has begun!

Source:  U.S. Department of Health & Human Services – http://www.womenshealth.gov/Pregnancy/you-are-pregnant/stages-of-pregnancy.cfm ; womenshealth.org

Pregnancy loss can happen in different ways. With a miscarriage, pregnancy suddenly ends before 20 weeks. It usually happens because of genetic problems in the fetus. An ectopic pregnancy occurs outside the uterus and the fetus cannot survive. In a molar pregnancy, a mass or growth forms inside the uterus at the beginning of a pregnancy; often there is no fetus. After 20 weeks, losing a pregnancy is called stillbirth.

Similar losses – and grief – can also be the result of newborn death or prenatal death from trauma. Counseling may help. Later, if you do decide to try again, work closely with your health care provider to lower the risks. Many women who lose a pregnancy go on to have healthy babies.

Source: National Library of Medicine, National Institutes of Health, MedlinePlus - http://www.nlm.nih.gov/medlineplus/pregnancyloss.html

Yet, the early history of cesarean section remains shrouded in myth and is of dubious accuracy. Even the origin of “cesarean” has apparently been distorted over time. It is commonly believed to be derived from the surgical birth of Julius Caesar, however this seems unlikely since his mother Aurelia is reputed to have lived to hear of her son’s invasion of Britain. At that time the procedure was performed only when the mother was dead or dying, as an attempt to save the child for a state wishing to increase its population. Roman law under Caesar decreed that all women who were so fated by childbirth must be cut open; hence, cesarean. Other possible Latin origins include the verb “caedare,” meaning to cut, and the term “caesones” that was applied to infants born by postmortem operations. Ultimately, though, we cannot be sure of where or when the term cesarean was derived. Until the sixteenth and seventeenth centuries the procedure was known as cesarean operation. This began to change following the publication in 1598 of Jacques Guillimeau’s book on midwifery in which he introduced the term “section.” Increasingly thereafter “section” replaced “operation.”

During its evolution cesarean section has meant different things to different people at different times. The indications for it have changed dramatically from ancient to modern times. Despite rare references to the operation on living women, the initial purpose was essentially to retrieve the infant from a dead or dying mother; this was conducted either in the rather vain hope of saving the baby’s life, or as commonly required by religious edicts, so the infant might be buried separately from the mother. Above all it was a measure of last resort, and the operation was not intended to preserve the mother’s life. It was not until the nineteenth century that such a possibility really came within the grasp of the medical profession.

There were, though, sporadic early reports of heroic efforts to save women’s lives. While the Middle Ages have been largely viewed as a period of stagnation in science and medicine, some of the stories of cesarean section actually helped to develop and sustain hopes that the operation could ultimately be accomplished. Perhaps the first written record we have of a mother and baby surviving a cesarean section comes from Switzerland in 1500 when a sow gelder, Jacob Nufer, performed the operation on his wife. After several days in labor and help from thirteen midwives, the woman was unable to deliver her baby. Her desperate husband eventually gained permission from the local authorities to attempt a cesarean. The mother lived and subsequently gave birth normally to five children, including twins. The cesarean baby lived to be 77 years old. Since this story was not recorded until 82 years later historians question its accuracy. Similar skepticism might be applied to other early reports of abdominal delivery þ those performed by women on themselves and births resulting from attacks by horned livestock, during which the peritoneal cavity was ripped open.

The history of cesarean section can be understood best in the broader context of the history of childbirth and general medicine þ histories that also have been characterized by dramatic changes. Many of the earliest successful cesarean sections took place in remote rural areas lacking in medical staff and facilities. In the absence of strong medical communities, operations could be carried out without professional consultation. This meant that cesareans could be undertaken at an earlier stage in failing labor when the mother was not near death and the fetus was less distressed. Under these circumstances the chances of one or both surviving were greater. These operations were performed on kitchen tables and beds, without access to hospital facilities, and this was probably an advantage until the late nineteenth century. Surgery in hospitals was bedeviled by infections passed between patients, often by the unclean hands of medical attendants. These factors may help to explain such successes as Jacob Nufer’s.

By dint of his work in animal husbandry, Nufer also possessed a modicum of anatomical knowledge. One of the first steps in performing any operation is understanding the organs and tissues involved, knowledge that was scarcely obtainable until the modern era. During the sixteenth and seventeenth centuries with the blossoming of the Renaissance, numerous works illustrated human anatomy in detail. Andreas Vesalius’s monumental general anatomical text De Corporis Humani Fabrica, for example, published in 1543, depicts normal female genital and abdominal structures. In the eighteenth and early nineteenth centuries anatomists and surgeons substantially extended their knowledge of the normal and pathological anatomy of the human body. By the later 1800s, greater access to human cadavers and changing emphases in medical education permitted medical students to learn anatomy through personal dissection. This practical experience improved their understanding and better prepared them to undertake operations.

At the time, of course, this new type of medical education was still only available to men. With gathering momentum since the seventeenth century, female attendants had been demoted in the childbirth arena. In the early 1600s, the Chamberlen clan in England introduced obstetrical forceps to pull from the birth canal fetuses that otherwise might have been destroyed. Men’s claims to authority over such instruments assisted them in establishing professional control over childbirth. Over the next three centuries or more, the male-midwife and obstetrician gradually wrested that control from the female midwife, thus diminishing her role.

Part 1

Cesarean section has been part of human culture since ancient times and there are tales in both Western and non-Western cultures of this procedure resulting in live mothers and offspring. According to Greek mythology Apollo removed Asclepius, founder of the famous cult of religious medicine, from his mother’s abdomen. Numerous references to cesarean section appear in ancient Hindu, Egyptian, Grecian, Roman, and other European folklore. Ancient Chinese etchings depict the procedure on apparently living women. The Mischnagoth and Talmud prohibited primogeniture when twins were born by cesarean section and waived the purification rituals for women delivered by surgery.

The extraction of Asclepius from the abdomen of his mother Coronis by his father Apollo. Woodcut from the 1549 edition of Alessandro Beneditti's De Re Medica.

Yet, the early history of cesarean section remains shrouded in myth and is of dubious accuracy. Even the origin of “cesarean” has apparently been distorted over time. It is commonly believed to be derived from the surgical birth of Julius Caesar, however this seems unlikely since his mother Aurelia is reputed to have lived to hear of her son’s invasion of Britain. At that time the procedure was performed only when the mother was dead or dying, as an attempt to save the child for a state wishing to increase its population. Roman law under Caesar decreed that all women who were so fated by childbirth must be cut open; hence, cesarean. Other possible Latin origins include the verb “caedare,” meaning to cut, and the term “caesones” that was applied to infants born by postmortem operations. Ultimately, though, we cannot be sure of where or when the term cesarean was derived. Until the sixteenth and seventeenth centuries the procedure was known as cesarean operation. This began to change following the publication in 1598 of Jacques Guillimeau’s book on midwifery in which he introduced the term “section.” Increasingly thereafter “section” replaced “operation.”

One of the earliest printed illustrations of Cesarean section. Purportedly the birth of Julius Caesar. A live infant being surgically removed from a dead woman. From Suetonius’ Lives of the Twelve Caesars, 1506 woodcut.

During its evolution cesarean section has meant different things to different people at different times. The indications for it have changed dramatically from ancient to modern times. Despite rare references to the operation on living women, the initial purpose was essentially to retrieve the infant from a dead or dying mother; this was conducted either in the rather vain hope of saving the baby’s life, or as commonly required by religious edicts, so the infant might be buried separately from the mother. Above all it was a measure of last resort, and the operation was not intended to preserve the mother’s life. It was not until the nineteenth century that such a possibility really came within the grasp of the medical profession.

Cesarean section performed on a living woman by a female practitioner. Miniature from a fourteenth-century "Historie Ancienne."

There were, though, sporadic early reports of heroic efforts to save women’s lives. While the Middle Ages have been largely viewed as a period of stagnation in science and medicine, some of the stories of cesarean section actually helped to develop and sustain hopes that the operation could ultimately be accomplished. Perhaps the first written record we have of a mother and baby surviving a cesarean section comes from Switzerland in 1500 when a sow gelder, Jacob Nufer, performed the operation on his wife. After several days in labor and help from thirteen midwives, the woman was unable to deliver her baby. Her desperate husband eventually gained permission from the local authorities to attempt a cesarean. The mother lived and subsequently gave birth normally to five children, including twins. The cesarean baby lived to be 77 years old. Since this story was not recorded until 82 years later historians question its accuracy. Similar skepticism might be applied to other early reports of abdominal delivery þ those performed by women on themselves and births resulting from attacks by horned livestock, during which the peritoneal cavity was ripped open.

The female pelvic anatomy. From Andreas Vesalius' De Corporis Humani Fabrica, 1543.

The history of cesarean section can be understood best in the broader context of the history of childbirth and general medicine þ histories that also have been characterized by dramatic changes. Many of the earliest successful cesarean sections took place in remote rural areas lacking in medical staff and facilities. In the absence of strong medical communities, operations could be carried out without professional consultation. This meant that cesareans could be undertaken at an earlier stage in failing labor when the mother was not near death and the fetus was less distressed. Under these circumstances the chances of one or both surviving were greater. These operations were performed on kitchen tables and beds, without access to hospital facilities, and this was probably an advantage until the late nineteenth century. Surgery in hospitals was bedeviled by infections passed between patients, often by the unclean hands of medical attendants. These factors may help to explain such successes as Jacob Nufer’s.

By dint of his work in animal husbandry, Nufer also possessed a modicum of anatomical knowledge. One of the first steps in performing any operation is understanding the organs and tissues involved, knowledge that was scarcely obtainable until the modern era. During the sixteenth and seventeenth centuries with the blossoming of the Renaissance, numerous works illustrated human anatomy in detail. Andreas Vesalius’s monumental general anatomical text De Corporis Humani Fabrica, for example, published in 1543, depicts normal female genital and abdominal structures. In the eighteenth and early nineteenth centuries anatomists and surgeons substantially extended their knowledge of the normal and pathological anatomy of the human body. By the later 1800s, greater access to human cadavers and changing emphases in medical education permitted medical students to learn anatomy through personal dissection. This practical experience improved their understanding and better prepared them to undertake operations.

At the time, of course, this new type of medical education was still only available to men. With gathering momentum since the seventeenth century, female attendants had been demoted in the childbirth arena. In the early 1600s, the Chamberlen clan in England introduced obstetrical forceps to pull from the birth canal fetuses that otherwise might have been destroyed. Men’s claims to authority over such instruments assisted them in establishing professional control over childbirth. Over the next three centuries or more, the male-midwife and obstetrician gradually wrested that control from the female midwife, thus diminishing her role.

Part 2

In Western society women for the most part were barred from carrying out cesarean sections until the late nineteenth century, because they were largely denied admission to medical schools. The first recorded successful cesarean in the British Empire, however, was conducted by a woman. Sometime between 1815 and 1821, James Miranda Stuart Barry performed the operation while masquerading as a man and serving as a physician to the British army in South Africa.

Successful Cesarean section performed by indigenous healers in Kahura, Uganda. As observed by R. W. Felkin in 1879.

While Barry applied Western surgical techniques, nineteenth-century travelers in Africa reported instances of indigenous people successfully carrying out the procedure with their own medical practices. In 1879, for example, one British traveller, R.W. Felkin, witnessed cesarean section performed by Ugandans. The healer used banana wine to semi-intoxicate the woman and to cleanse his hands and her abdomen prior to surgery. He used a midline incision and applied cautery to minimize hemorrhaging. He massaged the uterus to make it contract but did not suture it; the abdominal wound was pinned with iron needles and dressed with a paste prepared from roots. The patient recovered well, and Felkin concluded that this technique was well-developed and had clearly been employed for a long time. Similar reports come from Rwanda, where botanical preparations were also used to anesthetize the patient and promote wound healing.

The Woman's Hospital of the State of New York, 1867. One of America's first large hospitals for the diseases of women.

While many of the earliest reports of cesarean section issue from remote parts of Europe and the United States and from places far removed from the latest developments in Western medicine, it was only with increased urbanization and the growth of hospitals that the operation began to be performed routinely. Most rural births continued to be attended by midwives in the late nineteenth and early twentieth centuries, but in the cities obstetrics — a hospital-based specialty — squeezed out midwifery. In urban centers large numbers of uprooted working class women gave birth in hospitals because they could not rely on the support of family and friends, as they could in the countryside. It was in these hospitals, where doctors treated many patients with similar conditions, that new obstetrical and surgical skills began to be developed.

A Cesarean patient prior to dressing the wound, 1822.

Special hospitals for women sprang up throughout the United States and Europe in the second half of the nineteenth century. Reflecting that period’s budding medical interest in the sexuality and the diseases of women, these institutions nurtured the emerging specialties and provided new opportunities for medical practitioners, as well as new treatments for patients. Specialties such as neurology and psychiatry centered on mental and nervous disorders and obstetrics and gynecology centered on the functions and disorders of the female reproductive tract.

Destructive scissors and crotchets. From William Smellie's A Sett of Anatomical Tables, 1754.

As a serious abdominal operation, the development of cesarean section both sustained and reflected changes within general surgery. In the early 1800s, when surgery still relied on age-old techniques, its practitioners were dreaded and viewed by the public as little better than barbers, butchers, and tooth pullers. Although many surgeons possessed the anatomical knowledge and the courage to perform serious procedures they had been limited by the patient’s pain and the problems of infection. Well into the 1800s surgery continued to be barbarous and the best operators were known for the speed with which they could amputate a limb or suture a wound.

Craniotomy. Perforation of the skull, removal of cranial contents, and extraction of the collapsed skull.

During the nineteenth century, however, surgery was transformed — both technically and professionally. A new era in surgical practice began in 1846 at Massachusetts General Hospital when dentist William T. G. Morton used diethyl ether while removing a facial tumor. This medical application of anesthesia rapidly spread to Europe. In obstetrics, though, there was opposition to its use based on the biblical injunction that women should sorrow to bring forth children in atonement for Eve’s sin. This argument was substantially demolished when the head of the Church of England, Queen Victoria, had chloroform administered for the births of two of her children (Leopold in 1853 and Beatrice in 1857). Subsequently, anesthesia in childbirth became popular among the wealthy and practical in cases of cesarean section.

Obstetrical forceps. Eighteenth century, France.

By the century’s close, a wide range of technological innovations had enabled surgeons to revolutionize their practice and to professionalize their position. Anesthetics permitted surgeons to take the time to operate with precision, to cleanse the peritoneal cavity, to record the details of their procedures, and to learn from their experiences. Women were spared the agony of operations and were less susceptible to shock, which had been a leading cause of post-operative mortality and morbidity.

As many doctors discovered, anesthesia allowed them to replace craniotomy with cesarean section. Craniotomy had been practiced for hundreds, perhaps even thousands, of years. This unhappy procedure involved the destruction (by instruments such as the crotchet) of the fetal skull and the piecemeal extraction of the entire fetus from the vagina. Although this was a gruesome operation, it entailed far lower risk to the mother than attempts to remove the fetus through an abdominal incision.

While obstetrical forceps helped to remove the fetus in some cases, they had limitations. They undoubtedly saved the lives of some babies who would otherwise have suffered craniotomy, but even when the mother’s life was saved, she might well suffer severely for the rest of her life from tears in the vaginal wall and perineum. The low forceps that are still commonly used today could cause vaginal tears, but they were less likely to do so than the high forceps that in the nineteenth century were too frequently employed. Inserted deep into the pelvis in cases of protracted labor, these instruments were associated with high levels of fetal damage, infection, and serious lacerations to the woman. Dangerous as it was, cesarean section may have seemed preferable in some instances when the fetus was trapped high in the pelvis. Where severe pelvic distortion or contraction existed, neither craniotomy nor obstetrical forceps were of any avail, and then cesarean section was probably the only hope.

Abdominal surgery to remove diseased ovarian tissue (ovariotomy). Surgeon and anesthesiologist in street clothes. From Thomas Spencer Wells, Diseases of the Ovaries, 1872.

While doctors and patients alike were encouraged by anesthesia to resort to cesarean section rather than craniotomy, mortality rates for the operation remained high, with the infections septicemia and peritonitis accounting for a large percentage of post-operative deaths. Prior to the establishment of the germ theory of disease and the birth of modern bacteriology in the second half of the nineteenth century, surgeons wore their street clothes to operate and washed their hands infrequently while passing from one patient to another. In the mid-1860s, the British surgeon Joseph Lister introduced an antiseptic method using carbolic acid, and many operators adopted some part of his antisepsis. Others, however, were concerned about its corrosiveness and experimented with various aseptic measures that emphasized cleanliness. By the end of the century antisepsis and asepsis gradually were making inroads into the problems of surgical infections.

Unfortunately, surgical techniques of that day also contributed to the appallingly high maternal mortality rates. According to one estimate not a single woman survived cesarean section in Paris between 1787 and 1876. Surgeons were afraid to suture the uterine incision because they thought internal stitches, which could not be removed, might set up infections and cause uterine rupture in subsequent pregnancies. They believed the muscles of the uterus would contract and close spontaneously. Such was not the case. As a result some women died of blood loss — more from infection.

Part 3

Once anesthesia, antisepsis, and asepsis were firmly established obstetricians were able to concentrate on improving the techniques employed in cesarean section. As early as 1876, Italian professor Eduardo Porro had advocated hysterectomy in concurrence with cesareans to control uterine hemorrhage and prevent systemic infection. This enabled him to reduce the incidence of post-operative sepsis. But his mutilating elaboration on cesarean section was soon obviated by the employment of uterine sutures. In 1882, Max Saumlnger, of Leipzig made such a strong case for uterine sutures that surgeons began to change their practice. Saumlnger’s monograph was based largely on the experience of U.S. healers (surgeons and empirics) who had used internal sutures. The silver wire stitches he recommended were themselves new, having been developed by America’s premier nineteenth-century gynecologist J. Marion Sims. Sims had invented his sutures to treat the vaginal tears (fistulas) that resulted from traumatic childbirth.

J. Marion Sims repairing a vesico-vaginal fistula with silver wire sutures. 1870

As cesarean section became safer, obstetricians increasingly argued against delaying surgery. Rather than waiting for many hours of unsuccessful labor, doctors such as Robert Harris in the United States, Thomas Radford in England, and Franz von Winckel in Germany opted for an early resort to the operation in order to improve the outcome. If the woman was not in a state of collapse when taken to surgery her recovery would be more certain, they claimed. This was an argument sweeping through the general surgical community and one that resulted in greater numbers of operations on an expanding patient population. In obstetrical surgery the new approach also assisted in reducing maternal and perinatal infant mortality rates.

As surgeons’ confidence in the outcome of their procedures increased, they turned their attention to other issues, including where to incise the uterus. Between 1880 and 1925, obstetricians experimented with transverse incisions in the lower segment of the uterus. This refinement reduced the risk of infection and of subsequent uterine rupture in pregnancy. A further modification — vaginal cesarean section — helped avoid peritonitis in patients who were already suffering from certain infections. The need for that form of section, however, was virtually eliminated in the post World War II period by the development of modern antibiotics. Penicillin was discovered by Alexander Fleming in 1928 and, after it was purified as a drug in 1940, became generally available and dramatically reduced maternal mortality for both normal and cesarean section births. Meanwhile, the low cervical cesarean section, advocated in the early twentieth century by the British obstetrician Munro Kerr, had become popular. Promulgated by Joseph B. DeLee and Alfred C. Beck in the United States, this technique reduced the rates of infection and of uterine rupture and is still the operation of preference.

In addition to surgical advances, the development of cesarean section was influenced by the continued growth in number of hospitals, by significant demographic changes, and by numerous other factors — including religion. Religion has affected medicine throughout recorded history and, as noted earlier, both Jewish and Roman law helped shape early medical practice. Later, in early to mid-nineteenth century France, Roman Catholic religious concerns, such as removal of the infant so that it could be baptized, prompted substantial efforts to pioneer cesarean section, efforts launched by some of the country’s leading surgeons. Protestant Britain avoided cesarean section during the same period, even though surgeons were experimenting with other forms of abdominal procedures (mainly ovarian operations). British obstetricians were far more inclined to consider the mother primarily and, with cesarean section maternal mortality over fifty percent, they usually opted for craniotomy.

J. Marion Sims repairing a vesico-vaginal fistula with silver wire sutures. 1870

As the rate of urbanization rapidly increased in Britain, throughout Europe, and the United States there arose at the turn of the century an increased need for cesareans. Cut off from agricultural produce and exposed to little sunlight, city children experienced a sharply elevated rate of the nutritional disease rickets. In women where improper bone growth had resulted, malformed pelvises often prohibited normal delivery. As a result the rate of cesarean section went up markedly. By the 1930s, when safe milk became readily available in schools and clinics in much of the United States and Europe, improper bone growth became less of a problem. Yet, many in the medical profession were slow to respond to the decreased need for surgical delivery. After World War II, in fact, the cesarean section rate never returned to the low levels experienced before rickets became a large-scale malady, despite considerable criticism of the too frequent resort to surgery.

The safe milk movement was a measure of preventive medicine promoted by public health reformers in the United States and abroad. These reformers worked with governments to improve many aspects of maternal and infant health. Yet while more and more women received prenatal attention — indeed more than ever before — surgical intervention continued to rise. So too did the involvement of state and federal governments in financing and overseeing maternal and fetal care. Accompanying these trends was a tendency over the past half century for the status of the fetus increasingly to be given center stage.

Since 1940, the trend toward medically managed pregnancy and childbirth has steadily accelerated. Many new hospitals were built in which women gave birth and in which obstetrical operations were performed. By 1938, approximately half of U.S. births were taking place in hospitals. By 1955, this had risen to ninety-nine percent.

During that same period medical research flourished and technology was greatly expanded in scope and application. Advances in anesthesia contributed to improving the safety and the experience of cesarean section. In numerous countries, including the United States, spinal or epidural anesthesia is used to alleviate pain in normal childbirth. It has also largely replaced general anesthesia in cesarean deliveries, permitting women to remain conscious during surgery. It results in better outcomes for mothers and babies and facilitates immediate contact and bonding to occur.

These days, too, fathers are able to make that important early contact and support their partners during both normal and cesarean births. When childbirth was moved from homes to hospitals fathers were initially removed from the birthing scene and this distancing became even more complete in relation to surgical delivery. But, the use of conscious anesthesia and the increased ability to maintain an antiseptic and antibiotic field during operations allowed fathers to be present during cesarean section. Meanwhile, changes in gender relations were altering the involvement of many fathers in pregnancy, childbirth, and parenting. The modern father participates in childbirth classes and seeks a prominent role in birthing — normal and cesarean.

Currently in the United States slightly more than one in seven women experiences complications during labor and delivery that are due to conditions existing prior to pregnancy; these include diabetes, pelvic abnormalities, hypertension, and infectious diseases. In addition, a variety of pathological conditions that develop during pregnancy (such as eclampsia and placenta praevia) are indications for surgical delivery. These problems can be life-threatening for both mother and baby, and in approximately forty percent of such cases cesarean section provides the safest solution. In the United States almost one quarter of all babies are now delivered by cesarean section — approximately 982,000 babies in 1990. In 1970, the cesarean section rate was about 5%; by 1988, it had peaked at 24.7%. In 1990, it had decreased slightly to 23.5%, primarily because more women were attempting vaginal births after cesarean deliveries.

How can we explain this dramatic increase? It certainly far exceeds any rise in the birth rate, which went up by only 2% between 1970 and 1987. In fact there were several factors that contributed to the rapid rise in cesarean sections. Some of the factors were technological, some cultural, some professional, others legal. The growth in malpractice suits no doubt promoted surgical intervention, but there were many other influences at work.

Part 4

While the operation historically has been performed largely to protect the health of the mother, more recently the health of the fetus has played a larger role in decisions to go to surgery. Hormonal pregnancy tests — tests that confirm fetal existence — have been available since the 1940’s. The fetal skeleton could be seen using X-rays, but, the long-term hazards of radiation prompted researchers to seek other imaging technology. The answer in the post-war era came from wartime technology. Ultrasound, or sonar equipment that had been developed to detect submarines, became the springboard for soft tissue ultrasonography in the late 1940’s and early 1950’s. Ultrasound made it possible to measure fetal growth and fetal skull width in relation to the mother’s pelvic dimensions and now has become a routine diagnostic device. While this type of visualization provided medical personnel with valuable information, it also influenced attitudes toward the fetus. When the fetus could be visualized and its sex and chromosomal makeup determined through this and other more modern tests such as amniocentesis and chorionic villus sampling, it became more of a person. Indeed, many fetuses were named months before birth.

The fetus then has become a patient. Today it can even be surgically and pharmaceutically treated in utero. This changes the emotional and financial investment both medical practitioners and expectant parents have in a fetus. This is even more pronounced after the commencement of labor when the fetus increasingly becomes the primary patient. Since the advent of heart monitors in the early 1970’s, fetal monitoring routinely tracks fetal heart rate and indicates any signs of distress. As a result of the ability to detect signs of fetal distress, many cesarean sections are swiftly undertaken to prevent such serious problems as brain damage due to oxygen deficiency.

With these innovations came criticism. Fetal monitoring as well as numerous other antenatal diagnostics have been faulted in recent years by some of the lay public and members of the medical profession. The American College of Obstetricians and Gynecologists and similar organizations in several other countries have been working to reduce some of the reliance on high-cost and high-tech features of childbirth and to encourage women to attempt normal delivery whenever possible.

The trend toward hospital births, including cesarean section, has been challenged. Since 1940, the experience of giving birth has become safer and less frightening, and many women have come to view that experience more positively. Thus was spawned the natural childbirth movement, a development fueled by the modern feminist movement, which has urged women to take greater responsibility for their own bodies and health care. The soaring cesarean section rate of the past two decades has also been questioned by lay people. Consumer advocacy organizations and women’s groups have been working to reduce what they see as unnecessary surgery. Some doctors have for many years expressed doubts about the rates of cesarean section. Recently many medical practitioners have responded to this situation and have begun to work with lay organizations to encourage more women to undertake normal delivery.

These efforts seem to be having some effect. Despite the recent increase in cesarean section rates there appears to be a leveling off þ the figure for 1988 was almost identical to that for 1987. Perhaps one of the most important factors is the changing opinion toward the formula “once a cesarean section, always a cesarean section.” This expression embodied the notion that once a woman had a cesarean she would require surgery for all subsequent deliveries. This was, apparently, the cause of the greatest increase in cesarean sections between 1980 and 1985. But many women were deeply concerned about that edict and the morbidity following major surgery. They organized vaginal-birth-after-cesarean groups to encourage normal births subsequent to surgery. Soaring health care costs have also contributed to efforts to avoid the more expensive cesarean births. The American College of Obstetricians and Gynecologists responded swiftly to calls from within the organization and from the patient population and in 1982, as a standard of care, recommended a trial of labor in selected cases of prior cesarean section. In 1988, the guidelines were expanded to include more women with previous cesarean births. Consequently, there was a steady increase in vaginal births after cesarean in the late 1980’s. In 1990, an estimated 90,000 women gave birth vaginally after cesarean section.

The trend in Western medicine seems now to be away from higher levels of cesarean section, and a new ten-year study by an Oxford University research team emphasizes this point. The study involved a comparison of cesarean section rates that average almost 25% in the United States and 9% in Great Britain, and suggests that the trends in the United States need to be questioned. This study indicates that, while cesarean section continues to be a procedure that saves the lives of mothers and infants and prevents disabilities, both the medical and lay communities must bear in mind that most births are normal and more births should progress without undue intervention.

As this brief history suggests, the indications for cesarean section have varied tremendously through our documented history. They have been shaped by religious, cultural, economic, professional, and technological developments — all of which have impinged on medical practice. The operation originated from attempts to save the soul, if not the life, of a fetus whose mother was dead or dying. Since ancient times, however, there have been occasional efforts to save the mother, and during the nineteenth century, systematic improvement of cesarean section techniques eventually led to lower mortality for women and their fetuses. Increasingly the operation was performed in cases where the mother’s health was considered endangered, in addition to those in which her life was immediately at stake. Finally, in the late twentieth century, in mainstream Western medical society the fetus has become the primary patient once labor has commenced. As a result, we have seen in the last 30 years a marked increase in resort to surgery on the basis of fetal health indications.

While there is sound reason to believe that cesarean section has been employed too frequently in some societies during the last two or three decades, the operation clearly changes the outcome favorably for a significant percentage of women and babies. In our society now women may be afraid of the pain of childbirth, but they do not expect it to kill them. Such could not be said of many women as late as the nineteenth century. Moreover, most women now expect their babies to survive birth. These are modern assumptions and ones that cesarean section has helped to promulgate. An operation that virtually always resulted in a dead woman and dead fetus now almost always results in a living mother and baby — a transformation as significant to the women and families involved as to the medical profession.

Selected References

Ackerknecht, Erwin H.,
A Short History of Medicine,
Baltimore: The Johns Hopkins University Press, 1982

Boley, J.P.,
“The History of Cesarean Section,”
Canadian Medical Association Journal,
Vol. 145, No. 4, 1991, pp. 319-322.

Donnison, Jean,
Midwives and Medical Men: A History of the Struggle for the Control of Childbirth,
London: Historical Publications Ltd., 1988.

Eastman, N.J.,
“The Role of Frontier America in the Development of Cesarean Section,”
American Journal of Obstetrics and Gynecology,
Vol. 24, 1932, p. 919.

Gabert, Harvey A., “History and Development of Cesarean Operation,” in Obstetrics and Gynecology Clinics of North America,
Vol. 15, No. 4. 1988, pp. 591-605.

Horton, Jacqueline A., ed.,
The Women’s Health Data Book.
A Profile of Women’s Health in the United States,
New York: Elsevier, 1992, pp. 18-20.

Leavitt, Judith Walzer,
Brought to Bed: Childbearing in America, 1750-1950,
New York: Oxford University Press, 1986.

Leonardo, Richard A.,
History of Gynecology,
New York: Froben Press, 1944.

Ludmerer, Kenneth M.,
Learning to Heal: The Development of American Medical Education,
New York: Basic Books Inc., 1985.

Martin, Emily,
The Woman in the Body: A Cultural Analysis of Reproduction,
Boston: Beacon Press, 1987.

Maulitz, Russell C.,
Morbid Appearances: The Anatomy of Pathology in the Early Nineteenth Century,
Cambridge: Cambridge University Press, 1987.

Miller, Joseph L.,
“Cesarean Section in Virginia in the Pre-Aseptic Era, 1794-1879,”
Annals of Medical History, January, 1938, pp. 23-35.

Miller, Joseph M.,
“First Successful Cesarean Section in the British Empire,” Letters,
Vol. 166, No. 1, Part 1, p. 269.

Moscucci, Ornella,
The Science of Woman: Gynaecology and Gender in England, 1800-1929,
Cambridge: Cambridge University Press, 1990.

Oakley, Ann,
The Captured Womb: A History of the Medical Care of Pregnant Women,
Oxford: Basil Blackwell Ltd., 1984, 1986.

Pernick, Martin S.,
A Calculus of Suffering: Pain, Professionalism, and Anesthesia in Nineteenth-Century America,
New York: Columbia University Press, 1985.

Ricci, J.V.,
The Genealogy of Gynaecology: History of the Development of Gynaecology Throughout the Ages,
Philadelphia: The Blakiston Company, 1943.

Ricci, J.V.,
One Hundred Years of Gynaecology, 1800-1900,
Philadelphia: The Blakiston Company, 1945.

Rothstein, William G.,
American Medical Schools and the Practice of Medicine: A History,
New York: Oxford University Press, 1987.

Rucker M. Pierce and Edwin M. Rucker,
“A Librarian Looks at Cesarean Section,”
Bulletin of the History of Medicine, March 1951, pp. 132-148.

Sewell, Jane Eliot,
Bountiful Bodies: Spencer Wells, Lawson Tait, and the Birth of British Gynaecology,
Ann Arbor, Michigan: U.M.I., 1990.

Shryock, Richard Harrison,
The Development of Modern Medicine: An Interpretation of the Social and Scientific Factors Involved,
Madison, Wisconsin: The University of Wisconsin Press, 1936, 1979.

Shryock, Richard Harrison,
Medicine and Society in America: 1660-1860,
Ithaca: Cornell University Press, 1977.

Speert, Harold,
Obstetrics and Gynecology in America: A History,
Baltimore: Waverly Press, 1980.

Towler, Jean and Joan Bramell,
Midwives in History and Society,
London: Croom Helm, 1986.

Wertz, Richard W. and Dorothy C. Wertz,
Lying-In: A History of Childbirth in America,
New Haven: Yale University Press, 1989.

Willson, J. Robert,
“The Conquest of Cesarean Section-Related Infections: A Progress Report,”
Obstetrics and Gynecology, Vol. 72, No. 3, Part 2, September 1988, pp. 519-532.

Wolfe, Sidney M.,
Women’s Health Alert,
Reading, Massachusetts: Addison-Wesley Publishing Company Inc., 1991

Young, J.H.,
Caesarean Section: The History and Development of the Operation From Early Times,
London: H.K. Lewis and Co. Ltd., 1944.

The National Library of Medicine has a rich collection of written works on the history of Cesarean section as well as numerous film and other visual sources.

Source: National Library of Medicine, National Institutes of Health – https://www.nlm.nih.gov/exhibition/cesarean/

• Health problems in the mother
• The position of the baby
• Not enough room for the baby to go through the vagina
• Signs of distress in the baby

C-sections are also more common among women carrying more than one baby.

The surgery is relatively safe for mother and baby. Still, it is major surgery and carries risks. It also takes longer to recover from a C-section than from vaginal birth. After healing, the incision may leave a weak spot in the wall of the uterus. This could cause problems with an attempted vaginal birth later. However, more than half of women who have a C-section can give vaginal birth later.

Source: National Library of Medicine, National Institutes of Health, MedlinePlus – http://www.nlm.nih.gov/medlineplus/cesareansection.html

Korean Association for Voluntary Sterilization, Seoul.

Abstract

Three hundred and sixty-one women were provided government-funded sterilization reversal services with the technique of microsurgery. A large majority of reasons (89.8%) for requesting reversal surgery was a loss of children, and the mean interval between sterilization and reversal was 28.7 months. Two hundred and seven (69.7%) of 297 follow-up cases have experienced term delivery or intra-uterine pregnancy and 5 cases were ectopic pregnancy. The largest number of reversal clients (63.3%) were sterilized by the laparoscopic unipolar coagulation technique and the next largest group (24.2%) was sterilized by the laparoscopic banding technique. The highest pregnancy rate (77.8%) was shown in clients who had undergone laparoscopic banding technique while the lowest (65.9%) was the group of laparoscopic unipolar coagulation. A more than 60% of the clients became pregnant within 6 months of their reversal surgery, with the shortest interval being 1 month, the longest 39 months, and the mean 7.6 months. A large majority of the successful cases, 81.6%, were pregnant within 1 year of their reversal surgery.

PIP: Physicians at 15 institutions in the Republic of Korea conducted microsurgery to reverse tubal sterilization in 361 22-38 year old women (mean 28.8 years) of parity 0-2 (mean 0.4) between 1980 and 1988. The government paid for the sterilization reversal services. The leading reason for regret and reversal of tubal sterilization was death of a child (89.8%). The researchers were able to follow up on 297 cases (18 months-8 years after reversal surgery). 69.7% (207) of the cases became pregnant after tubal sterilization. Most reversal clients (63.3%) had had laparoscopic unipolar coagulation followed by the laparoscopic banding technique (24.2%). The laparoscopic banding technique resulted in a more successful reversal rate (77.8%), however. Only 65.9% of clients who had had laparoscopic unipolar coagulation became pregnant. The most successful reversal by sterilization type was for clients who had had postpartum Pomeroy technique (90%). The most successful reversal by anastomosis site was isthmic-isthmic (80.9%) and the least successful was cornual-ampullary (64.9%). 61.8% became pregnant within 6 months after reversal and 81.6% within 1 year. The success rate was highest among the women who underwent their reversal 25-36 months after the sterilization (78.4%) and the lowest rate among those with an interval of 37-48 months (53.5%). The mean interval between reversal and conception was 7.6 months, the shortest interval being 1 month and the longest 39 months. As voluntary sterilization occurs more often at lower parity among younger women, Korea expects to continue to see more sterilization reversal requests.

Source: U.S. National Library of Medicine, National Institutes of Health – http://www.ncbi.nlm.nih.gov/pubmed/1627062

Contents

1. Basic obstetric terms
2. Complications of pregnancy and childbirth
3. See also

Basic obstetric terms

• amniocentesis
• amnion, amniotic sac
• amniotic fluid
• antenatal care, prenatal care
• breastfeeding
• cervix
• childbirth
• chorionic villus sampling
• contraception
• embryo
• embryology
• fallopian tube
• fetus
• gestation
• gynecology
• hormone
• identical twin
• In Vitro Fertilization (IVF)
• labor, labour – see childbirth
• lactation
• Lamaze
• live birth
• menstrual cycle
• midwifery
• mother
• natural childbirth
• navel
• ovary
• ovum or egg
• oxytocin or pitocin
• pediatrics
• pelvic bone width
• placenta
• pregnancy
• sterilization
• twin
• ultrasound
• umbilical cord
• umbilicus – see navel
• uterus or womb
• vagina
• womb – see uterus

Complications of pregnancy and childbirth

• abortion
• abruption
• breech birth
• cephalo-pelvic disproportion
• caesarean section, cesarean section, C-section
• dermatoses of pregnancy specific skin conditions during pregnancy
• diabetes
• eclampsia
• ectopic pregnancy
• gestational diabetes
• Group B Streptococcus infection
• HELLP syndrome
• hypertension
• hysterectomy
• Intrauterine Growth Restriction (IUGR)
• macrosomia (big baby)
• malpractice
• miscarriage or stillbirth
• obstetric fistula
• obstetric hemorrhage
• Pelvic girdle pain
• placenta praevia
• pre-eclampsia
• premature birth, preterm labor or prematurity
• small for gestational age (SGA)
• uterine rupture

See also

• gynecology – study of female reproductive system
• Samantha Burton v. State of Florida

Source: http://en.wikipedia.org/wiki/List_of_obstetric_topics

Antenatal care

In obstetric practice, an obstetrician or midwife sees a pregnant woman on a regular basis to check the progress of the pregnancy, to verify the absence of ex-novo disease, to monitor the state of preexisting disease and its possible effect on the ongoing pregnancy. A woman’s schedule of antenatal appointment varies according to the presence of risk factors, such as diabetes, and local resources.

Some of the clinically and statistically more important risk factors that must be systematically excluded, especially in advancing pregnancy, are pre-eclampsia, abnormal placentation, abnormal fetal presentation and intrauterine growth restriction. For example, to identify pre-eclampsia, blood-pressure and albuminuria (level of urine protein) are checked at every opportunity.

Placenta praevia must be excluded (PP = low lying placenta that, at least partially, obstructs the birth canal and therefore warrants elective caesarean delivery); this can only be achieved with the use of an ultrasound scan. However, early placenta praevia is not alarming; this is because as the uterus grows along the pregnancy, the placenta may still move away. A placenta praevia is of clinical significance as from the 28th week of gestation. The current management includes a caesarean section. The type of caesarean section is determined by the position (anterior or posterior) of the placenta.

In late pregnancy fetal presentation must be established: cephalic presentation (head first) is the norm but the fetus may present feet-first or buttocks-first (breech), side-on (transverse), or at an angle (oblique presentation).

Intrauterine growth restriction is a general designation where the fetus is smaller than expected when compared to its gestational age (in this case, fetal growth parameters show a tendency to drop off from the 50th percentile eventually falling below the 10th percentile, when plotted on a fetal growth chart).^{[citation needed]} Causes can be intrinsic (to the fetus) or extrinsic (maternal or placental problems).

Maternal change

Cardiovascular

The woman is the sole provider of nourishment for the embryo and later, the fetus, and so her plasma and blood volume slowly increase by 40-50% over the course of the pregnancy to accommodate the changes.^[1] This results in overall vasodilation, an increase in heart rate (15 beats/min more than usual), stroke volume, and cardiac output. Cardiac output increases by about 50%, mostly during the first trimester. The systemic vascular resistance also drops due to the smooth muscle relaxation caused by elevated progesterone, leading to a fall in blood pressure. Diastolic blood pressure consequently decreases between 12–26 weeks, and increases again to pre-pregnancy levels by 36 weeks. If the blood pressure becomes abnormally high, the woman should be investigated for pre-eclampsia and other causes of hypertension.

Endocrine

Pregnant women experience adjustments in their endocrine system. These adjustments include an increase in her estrogen levels; which is mainly produced by the placenta and is associated with fetal well–being. Women also experience increased human chorionic gonadotropin (β-hCG); which is produced by the placenta. This maintains progesterone production by the corpus luteum. Additionally, human placental lactogen(hPL) is produced by the placenta, ensuring nutrient supply to the fetus. This also causes lipolysis and is an insulin antagonist, which is a diabetogenic effect.

Additionally, there is increased prolactin, increased alkaline phosphatase, and increased progesterone production, first by corpus luteum and later by the placenta, whose main course of action is to relax smooth muscle.

Gastrointestinal

During pregnancy, woman can experience nausea and vomiting (morning sickness); which may be due to elevated B-hCG and should resolve by 14 to 16 weeks.^{[citation needed]} Additionally, there is prolonged gastric empty time, decreased gastroesophageal sphincter tone, which can lead to acid reflux, and decreased colonic motility, which leads to increased water absorption and constipation.

Hematology

During pregnancy the plasma volume increases by 50% and the red blood cell volume increases only by 20-30%.^[1] Consequently, thehematocrit decreases on lab value; this is not a true decrease in hematocrit, however, but rather due to the dilution. The white blood cell count increases and may peak at over 20 mg/mL in stressful conditions. Conversely, there is a decrease in platelet concentration to a minimal normal values of 100-150 mil/mL.

A pregnant woman will also become hypercoagulable, leading to increased risk for developing blood clots and embolisms, due to increased liverproduction of coagulation factors, mainly fibrinogen and factor VIII (this hypercoagulable state along with the decreased ambulation causes an increased risk of both DVT and PE). Women are at highest risk for developing clots, or thrombi, during the weeks following labor. Clots usually develop in the left leg or the left iliac venous system. The left side is most afflicted because the left iliac vein is crossed by the right iliac artery. The increased flow in the right iliac artery after birth compresses the left iliac vein leading to an increased risk for thrombosis (clotting) which is exacerbated by the aforementioned lack of ambulation following delivery. Both underlying thrombophilia and cesarean section can further increase these risks.

Edema, or swelling, of the feet is common during pregnancy, partly because the enlarging uterus compresses veins and lymphatic drainage from the legs.

Metabolism

During pregnancy, both protein metabolism and carbohydrate metabolism are affected. One kilogram of extra protein is deposited, with half going to the fetus and placenta, and another half going to uterine contractile proteins, breast glandular tissue, plasma protein, and haemoglobin.

Neurophysiologic

During pregnancy, the woman undergoes many physiological changes, which are entirely normal, including cardiovascular, hematologic,metabolic, renal and respiratory changes that become very important in the event of complications. The body must change its physiological and homeostatic mechanisms in pregnancy to ensure the fetus is provided for. Increases in blood sugar, breathing and cardiac output are all required. Levels of progesterone and oestrogens rise continually throughout pregnancy, suppressing the hypothalamic axis and subsequently the menstrual cycle. The woman and the placenta also produce many hormones.

Prolactin levels increase due to maternal Pituitary gland enlargement by 50%. This mediates a change in the structure of the Mammary gland from ductal to lobular-alveolar. Parathyroid hormone is increased due to increases of calcium uptake in the gut and reabsorption by the kidney. Adrenal hormones such as cortisol and aldosterone also increase.

Placental lactogen is produced by the placenta and stimulates lipolysis and fatty acid metabolism by the woman, conserving blood glucose for use by the fetus. It can also decrease maternal tissue sensitivity to insulin, resulting in gestational diabetes.

Nutrition

Nutritionally, pregnant women require a caloric increase caloric of 300 kcal/day and an increase in protein to 70 or 75 g/day.^{[citation needed]}There is also an increased folate requirement from 0.4 to 0.8 mg/day (important in preventing neural tube defects). On average, a weight gain of 20 to 30 lb (9.1 to 14 kg) is experienced.^{[citation needed]}

All patients are advised to take prenatal vitamins to compensate for the increased nutritional requirements. The use of Omega 3 fatty acids supports mental and visual development of infants.^[2] Choline supplementation of research mammals supports mental development that lasts throughout life.^[3]

Renal

A pregnant woman may experience an increase in kidney and ureter size. The glomerular filtration rate (GFR) commonly increases by 50%, returning to normal around 20 weeks postpartum.^[1] Plasma sodium does not change because this is offset by the increase in GFR. There is decreased blood urea nitrogen (BUN) and creatinine and glucosuria (due to saturated tubular reabsorption) may be seen. Persistent glucosuria may suggest gestational diabetes. The renin-angiotensin system is upregulated, causing increased aldosterone levels.

Pulmonary

Changes in pulmonary activity for pregnant woman can include increased tidal volume (30-40%), decreased total lung capacity (TLC) by 5% due to elevation of diaphragm from uteral compression, decreased expiratory reserve volume, and increased minute ventilation (30-40%) which causes a decrease in PaCO2 and a compensated respiratory alkalosis^[1]

All of these changes can contribute to the dyspnea (shortness of breath) that a pregnant woman may experience.

Other

Other conditions that can be encountered include:

• Lower back pain due to a shift in gravity
• Increased estrogen can cause spider angiomata and palmar erythema
• Increase melanocyte-stimulating hormone (MSH) can cause hyperpigmentation of nipples, umbilicus, abdominal midline (linea nigra), perineum, and face (melasma or chloasma)

Prenatal care

Prenatal care is important in screening for various complications of pregnancy. This includes routine office visits with physical exams and routine lab tests:

First trimester

• Complete blood count (CBC)
• Blood type
• General antibody screen (indirect Coombs test) for HDN
  • Rh D negative antenatal patients should receive RhoGam at 28 weeks to prevent Rh disease.
• Rapid plasma reagent (RPR) which screens for syphilis
• Rubella antibody screen
• Hepatitis B surface antigen
• Gonorrhea and Chlamydia culture
• PPD for tuberculosis
• Pap smear
• Urinalysis and culture
• HIV screen
• Group B Streptococcus screen – will receive IV penicillin or ampicillin (it is much cheaper and has a wider coverage)if positive (if mother is allergic, alternative therapies include IV clindamycin or IV vancomycin)

genetic screening for downs syndrome (trisomy 21) and trisomy 18 the national standard in the United States is rapidly evolving away from the AFP-Quad screen for downs syndrome- done typically in the second trimester at 16–18 weeks. The newer integrated screen (formerly called F.A.S.T.E.R for First And Second Trimester Early Results) can be done at 10 plus weeks to 13 plus weeks with an ultrasound of the fetal neck (thick skin is bad) and two chemicals (analytes) Papp-a and bhcg (pregnancy hormone level itself). It gives an accurate risk profile very early. There is then a second blood screen at 15 to 20 weeks which refines the risk more. The cost is higher than an afp-quad screen due to the ultrasound and second blood test but it is quoted to have a 92% pick up rate.

Second trimester

• MSAFP/quad. screen (four simultaneous blood tests) (maternal serum alpha-fetoprotein; inhibin; estriol; bhcg or free bhcg) – elevations, low numbers or odd patterns correlate with neural tube defect risk and increased risks of trisomy 18 or trisomy 21
• Ultrasound either abdominal or trannsvaginal to assess cervix, placenta, fluid and baby
• Amniocentesis is the national standard for women over 35 or who reach 35 by mid pregnancy or who are at increased risk by family history or prior birth history

Third trimester

• Hematocrit (if low, mother will receive iron supplementation)
• Glucose loading test (GLT) – screens for gestational diabetes; if > 140 mg/dL, a glucose tolerance test (GTT) is administered; a fasting glucose > 105 mg/dL suggests gestational diabetes.

Most doctors do a sugar load in a drink form of 50 grams of glucose in cola, lime or orange and draw blood an hour later (plus or minus 5 minutes) ; the standard modified criteria have been lowered to 135 since the late 1980s.

Complications

Fetal assessments

Ultrasound is routinely used for dating the gestational age of a pregnancy from the size of the fetus, the most accurate dating being in first trimester before the growth of the fetus has been significantly influenced by other factors. Ultrasound is also used for detecting congenital anomalies (or other fetal anomalies) and determining the biophysical profiles (BPP), which are generally easier to detect in the second trimester when the fetal structures are larger and more developed. Specialised ultrasound equipment can also evaluate the blood flow velocity in theumbilical cord, looking to detect a decrease/absence/reversal or diastolic blood flow in the umbilical artery.

Other tools used for assessment include:

• Fetal karyotype can be used for the screening of genetic diseases. This can be obtained via amniocentesis or chorionic villus sampling(CVS)
• Fetal hematocrit for the assessment of fetal anemia, Rh isoimmunization, or hydrops can be determined by percutaneous umbilical blood sampling (PUBS) which is done by placing a needle through the abdomen into the uterus and taking a portion of the umbilical cord.
• Fetal lung maturity is associated with how much surfactant the fetus is producing. Reduced production of surfactant indicates decreased lung maturity and is a high risk factor for infant respiratory distress syndrome. Typically a lecithin:sphingomyelin ratio greater than 1.5 is associated with increased lung maturity.
• Nonstress test (NST) for fetal heart rate
• Oxytocin challenge test

Childbirth

Induction

Induction is a method of artificially or prematurely stimulating labour in a woman. Reasons to induce can include pre-eclampsia, the birth mass, diabetes, and other various general medical conditions, such as renal disease. Induction may occur any time after 34 weeks of gestation if the risk to the fetus or mother is greater than the risk of delivering a premature fetus regardless of lung maturity. If a woman does not eventually labour by 41–42 weeks, induction may be performed, as the placenta may become unstable after this date.^{[citation needed]}

Induction may be achieved via several methods:

• Pessary of Prostin cream, prostaglandin E₂
• Intravaginal or oral administration of misoprostol
• Cervical insertion of a 30-mL Foley catheter
• Rupturing the amniotic membranes
• Intravenous infusion of synthetic oxytocin (Pitocin or Syntocinon)

Labor

During labor itself, the obstetrician/doctor/intern/medical student under supervision may be called on to do a number of tasks. These tasks can include:

• Monitor the progress of labor, by reviewing the nursing chart, performing vaginal examination, and assessing the trace produced by a fetal monitoring device (the cardiotocograph)
• Accelerate the progress of labor by infusion of the hormone oxytocin
• Provide pain relief, either by nitrous oxide, opiates, or by epidural anesthesia done by anaesthestists, an anesthesiologist, or a nurse anesthetist.
• Surgically assisting labor, by forceps or the Ventouse (a suction cap applied to the fetus’ head)
• Caesarean section, if there is an associated risk with vaginal delivery, as such fetal or maternal compromise supported by evidence and literature. Caesarean section can either be elective, that is, arranged before labor, or decided during labor as an alternative to hours of waiting. True “emergency” Cesarean sections include abruptio placenta, and are more common in multigravid patients, or patients attempting a Vaginal Birth After Caeserean section (VBAC).

Emergencies in obstetrics

The main emergencies include:

• Ectopic pregnancy is when an embryo implants in the Fallopian tube or (rarely) on the ovary or inside the peritoneal cavity. This may cause massive internal bleeding.
• Pre-eclampsia is a disease which is defined by a combination of signs and symptoms that are related to maternal hypertension. The cause is unknown, and markers are being sought to predict its development from the earlist stages of pregnancy. Some unknown factors cause vascular damage in the endothelium, causing hypertension. If severe, it progresses to eclampsia, where a convulsions occur, which can be fatal. Preeclamptic patients with the HELLP syndrome show liver failure and Disseminated intravascular coagulation (DIC).
• Placental abruption where the patient can bleed to death if not managed appropriately.
• Fetal distress where the fetus is getting compromised in the uterine environment.
• Shoulder dystocia where one of the fetus’ shoulders becomes stuck during vaginal birth, especially in macrosomic babies of diabetic mothers.
• Uterine rupture can occur during obstructed labor and endangered fetal and maternal life.
• Prolapsed cord refers to the prolapse of the fetal cord during labor with the risk of fetal suffocation.
• Obstetrical hemorrhage may be due to a number of factors such as placenta previa, uterine rupture of tears, uterine atony, retained placentaor placental fragments, or bleeding disorders.
• Puerperal sepsis is a progressed infection of the uterus during or after labor.

Imaging, monitoring and care

In present society, medical science has developed a number of procedures to monitor pregnancy.

Antenatal record

On the first visit to her obstetrician or midwife, the pregnant woman is asked to carry out the antenatal record, which constitutes a medical history and physical examination. On subsequent visits, the gestational age (GA) is rechecked with each visit.

Symphysis-fundal height (SFH; in cm) should equal gestational age after 20 weeks of gestation, and the fetal growth should be plotted on a curve during the antenatal visits. The fetus is palpated by the midwife or obstetrician using Leopold maneuver to determine the position of the baby. Blood pressure should also be monitored, and may be up to 140/90 in normal pregnancies. High blood pressure indicates hypertensionand possibly pre-eclampsia, if severe swelling (edema) and spilled protein in the urine are also present.

Fetal screening is also used to help assess the viability of the fetus, as well as congenital problems. Genetic counseling is often offered for families who may be at an increased risk to have a child with a genetic condition. Amniocentesis at around the 20th week is sometimes done for women 35 or older to check for Down’s Syndrome and other chromosome abnormalities in the fetus.

Even earlier than amniocentesis is performed, the mother may undergo the triple test, nuchal screening, nasal bone, alpha-fetoprotein screening and Chorionic villus sampling, also to check for disorders such as Down Syndrome. Amniocentesis is a prenatal genetic screening of the fetus, which involves inserting a needle through the mother’s abdominal wall and uterine wall, to extract fetal DNA from the amniotic fluid. There is a risk of miscarriage and fetal injury with amniocentesis because it involves penetrating the uterus with the baby still in utero.

Imaging

Imaging is another important way to monitor a pregnancy. The mother and fetus are also usually imaged in the first trimester of pregnancy. This is done to predict problems with the mother; confirm that a pregnancy is present inside the uterus; estimate the gestational age; determine the number of fetuses and placentae; evaluate for an ectopic pregnancy and first trimester bleeding; and assess for early signs of anomalies.

X-rays and computerized tomography (CT) are not used, especially in the first trimester, due to theionizing radiation, which has teratogenic effects on the fetus. Instead, ultrasound is the imaging method of choice in the first trimester and throughout the pregnancy, because it emits no radiation, is portable, and allows for realtime imaging.

Ultrasound imaging may be done at any time throughout the pregnancy, but usually happens at the 12th week (dating scan) and the 20th week (detailed scan).

A normal gestation would reveal a gestational sac, yolk sac, and fetal pole. The gestational age can be assessed by evaluating the mean gestational sac diameter (MGD) before week 6, and the crown-rump length after week 6. Multiple gestation is evaluated by the number ofplacentae and amniotic sacs present.

Salary

The salary of a obstetrician varies from country to country:in the united states they can make anywhere for 200,000 to 339,738

References

1. ^ ^{a b c d} Guyton and hall (2005) (in en). Textbook of Medical Physiology (11 ed.). Philadelphia: Saunders. pp. 103g. ISBN 81-8147-920-3.
2. ^ “Omega-3 least known of pregnancy “Big 3″”. Retrieved 2008-01-01.
3. ^ Tees RC, Mohammadi E (1999). “The effects of neonatal choline dietary supplementation on adult spatial and configural learning and memory in rats”. Dev Psychobiol 35 (3): 226–40. doi:10.1002/(SICI)1098-2302(199911)35:3<226::AID-DEV7>3.0.CO;2-H. PMID 10531535.
4. ^ Obstetrician working in United Kingdom, UK Salary, SalaryExpert.com, Retrieved on 2009-03-23
5. ^ Obstetrician working in United Arab Emirates, SalaryExpert.com. Retrieved on 2009-03-23

Further reading

• Lane, J (July 1987). ”A provincial surgeon and his obstetric practice: Thomas W. Jones of Henley-in-Arden, 1764–1846″. Medical History31 (3): 333–48. PMID 3306222.
• Stockham, Alice B. Tokology. A Book for Every Woman. o.O., (Kessinger Publishing) o.J. Reprint of Revised Edition Chicago, Alice B. Stockham & Co. 1891 (first edition 1886). ISBN: 1-4179-4001-8

Source: http://en.wikipedia.org/wiki/Obstetrics