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RECOMMENDED CORE EDUCATIONAL GUIDELINES FOR FAMILY PRACTICE RESIDENTS

Maternity and Gynecologic Care

This document was developed by a joint task force of the American Academy of Family Physicians and the American College of Obstetricians and Gynecologists.

These core educational guidelines in maternity and gynecologic care for family practice residents are intended to aid residency directors in developing curricula and to assist residents in identifying areas of necessary training. Following these recommendations, which are designed as curricular guidelines rather than as residency program requirements, should result in graduates of family practice residency programs who are well-prepared to provide quality medical care in the areas of maternity care, labor and delivery, and the female reproductive system. These curricular guidelines are not intended to serve as criteria for hospital privileging or credentialing. The assignment of hospital privileges is a local responsibility and is based on training, experience and current competence.

Curriculum

Core knowledge and skills should require a minimum of three months of experience in a structured obstetric-gynecologic educational program, with adequate emphasis on ambulatory and hospital care. Residents will obtain substantial additional obstetric-gynecologic experience throughout the three years of their experience in family practice centers and in their continuity practices. Residents will return to the family practice centers for their scheduled continuity clinics.

The most important objective in family practice residency training should be to provide consistent, quality, evidence-based care. While there may be different approaches to patient care, in all cases, social and psychologic aspects of care, as well as an appropriate history and physical examination, must be an integral part of training. The knowledge, skills and judgment required in residency training are a necessary base, although they might not necessarily translate into the practice of every family physician.

Programs for family practice residents should have a joint training committee composed of obstetrician-gynecologists and family physicians, with members of the committee approved by the chairs of the respective departments in the sponsoring educational institution. It shall be the responsibility of the joint training committee to develop objectives commensurate with the goals of the training program, to monitor residents' experience and to assist in the evaluation of faculty teaching skills. Educational institutions sponsoring graduate medical education should assume corporate responsibility for the overall program.

Family physicians and obstetricians should collaborate on the design, implementation and evaluation of the training of family practice residents in obstetrics-gynecology. A curriculum in obstetrics-gynecology for family practice residents should incorporate knowledge of diagnosis and management, core skills and advanced skills. In this document, management implies responsibility for and provision of care and, when necessary, consultation and/or referral.

1. Knowledge of diagnosis and management
   1. Normal female growth and development, and variants
   2. Appropriate history and physical examination for all age groups
   3. Gynecology
      1. Disease prevention/health promotion and periodic health evaluation
      2. Physiology of menstruation
      3. Abnormal uterine bleeding
      4. Gynecologic problems of children
      5. Infections and diseases of the female reproductive and urinary systems
      6. Breast health and diseases of the breast
      7. Sexual assault
      8. Domestic violence
      9. Trauma to the reproductive system
      10. Pelvic pain
      11. Benign and malignant neoplasms of the female reproductive system
      12. Menopause and geriatric gynecology
      13. Indications for surgical intervention
      14. Cervical lesions and abnormal cytology
      15. Ectopic pregnancy
   4. Obstetrics
      1. Prepregnancy planning and counseling
      2. Prenatal care, including risk assessment
      3. Labor and delivery
      4. Postpartum care
      5. Care of the normal newborn
      6. Common neonatal problems
      7. Analgesia and anesthesia for labor and delivery
      8. Indications for cesarean delivery
      9. Obstetric complications and emergencies
      10. Lactation
   5. Family life education
      1. Family planning
      2. Fertility problems
      3. Interconceptional care
      4. Family and sexual counseling
   6. Consultation and referral
      1. The role of the obstetrician, gynecologist and subspecialist
      2. Women's health care delivery systems
      3. Regionalized perinatal care for high-risk pregnancies
      4. Collaboration with other health care providers (i.e., nutritionist, dietitian, childbirth educator, lactation consultant, certified nurse midwife, nurse practitioner, etc.)

2. Core skills
   Emotional preparation for, and a sensitive, thorough performance of, the gynecologic examination in patients of all ages.
   1. Gynecology
      1. Appropriate screening examination of the female, including breast examination
      2. Obtaining vaginal and cervical cytology
      3. Colposcopy
      4. Cervical biopsy, polypectomy
      5. Endometrial biopsy
      6. Culdocentesis
      7. Cryosurgery/cautery for benign disease
      8. Microscopic diagnosis of urine and vaginal smears
      9. Bartholin duct cyst drainage or marsupialization
      10. Dilation and curettage for incomplete abortion
   2. Family planning and contraception
      1. Oral contraceptive counseling and prescribing
      2. Intrauterine contraceptive device counseling, insertion and removal
      3. Diaphragm fitting and counseling
      4. Insertion and removal of subcutaneous contraceptive implants and counseling
      5. Injectable long-term contraceptives and counseling
   3. Pregnancy
      1. Prepregnancy evaluation
      2. Initial pregnancy visit
      3. Risk assessment
      4. History, physical examination, laboratory monitoring, and counseling throughout pregnancy
      5. Noninvasive evaluation of fetal gestational age and fetoplacental adequacy, including limited obstetric ultrasound examination
      6. Management of labor
      7. Pudendal and local block anesthesia
      8. Fetal assessment, antepartum and intrapartum, including limited obstetric ultrasound examination
      9. Induction of labor
      10. Internal fetal monitoring
      11. Normal cephalic delivery including use of vacuum extraction and outlet forceps
      12. Episiotomy and repair, including third-degree lacerations
      13. Management of common intrapartum problems (e.g., hypertension, mild pre-eclampsia, fever, infection, nonreassuring fetal status, unanticipated shoulder dystocia, manual removal of placenta)
      14. Exploration of vagina, cervix, uterus
      15. Emergency breech delivery
      16. Neonatal resuscitation
      17. Management of common postpartum problems (e.g., hemorrhage, endometritis)
      18. First-assist at cesarean delivery
      19. Vaginal delivery after previous cesarean delivery
   4. Surgery
      1. Assist at common major surgical procedures

3. Advanced skills
   For family practice residents who are planning to practice in communities without readily available obstetric-gynecologic consultation and who need to provide a more complete level of obstetric-gynecologic services for the proper care of patients, additional, intensified experience is recommended. This experience should be agreed on by the joint training committee and tailored to the needs of the resident's intended practice; it may occur within the three-year family practice residency.
   
   Family practice residents planning to include the following in their practices should obtain additional intensified experience taught by or in collaboration with obstetrician-gynecologists. In programs where obstetrician-gynecologists are not available, these skills should be taught by appropriately skilled family physicians.
   1. Gynecology
      1. Loop electrosurgical excision procedures
   2. Family planning and contraception
      1. Voluntary interruption of pregnancy up to 10 weeks of gestation
   3. Pregnancy
      1. Ultrasound-guided amniocentesis, mid- and third-trimester
      2. Conduction anesthesia and analgesia (not routinely taught by obstetrician-gynecologists)
      3. Management of preterm labor
      4. Management of multiple gestation
      5. Management of breech delivery
      6. External cephalic version
      7. Amnioinfusion
      8. Use of low forceps
      9. Fourth-degree lacerations
      10. Severe pre-eclampsia
      11. Performance of cesarean delivery
      12. Management of complications of vaginal birth after previous cesarean delivery
   4. Surgery
      1. Tubal ligation, postpartum and with cesarean delivery

AAFP­ACOG Joint Statement on Cooperative Practice and Hospital Privileges

This document was developed by a joint task force of the American Academy of Family Physicians and the American College of Obstetricians and Gynecologists.

Access to maternity care is an important public health concern in the United States. Providing comprehensive perinatal services to a diverse population requires a cooperative relationship among a variety of health professionals, including social workers, health educators, nurses and physicians. Prenatal care, labor and delivery, and postpartum care have historically been provided by midwives, family physicians and obstetricians. All three remain the major caregivers today. A cooperative and collaborative relationship among obstetricians, family physicians and nurse midwives is essential for provision of consistent, high-quality care to pregnant women.

Regardless of specialty, there should be shared common standards of perinatal care. This requires a cooperative working environment and shared decision making. Clear guidelines for consultation and referral for complications should be developed jointly. When appropriate, early and ongoing consultation regarding a woman's care is necessary for the best possible outcome and is an important part of risk management and prevention of professional liability problems. All family physicians and obstetricians on the medical staff of the obstetric unit should agree to such guidelines and be willing to work together for the best care of patients. This includes a willingness on the part of obstetricians to provide consultation and back-up for family physicians who provide maternity care. The family physician should have knowledge, skills and judgment to determine when timely consultation and/or referral may be appropriate.

The most important objective of the physician must be the provision of the highest standards of care, regardless of specialty. Quality patient care requires that all providers practice within their degree of ability as determined by training, experience and current competence. A joint practice committee with obstetricians and family physicians should be established in health care organizations to determine and monitor standards of care and to determine proctoring guidelines. A collegial working relationship between family physicians and obstetricians is essential if we are to provide access to quality care for pregnant women in this country.

1. A. Practice privileges

   The assignment of hospital privileges is a local responsibility and privileges should be granted on the basis of training, experience and demonstrated current competence. All physicians should be held to the same standards for granting of privileges, regardless of specialty, in order to ensure the provision of high-quality patient care. Prearranged, collaborative relationships should be established to ensure ongoing consultations, as well as consultations needed for emergencies.
   
   The standard of training should allow any physician who receives training in a cognitive or surgical skill to meet the criteria for privileges in that area of practice. Provisional privileges in primary care, obstetric care and cesarean delivery should be granted regardless of specialty as long as training criteria and experience are documented. All physicians should be subject to a proctorship period to allow demonstration of ability and current competence. These principles should apply to all health care systems.

2. Interdepartmental relationships

   Privileges recommended by the department of family practice shall be the responsibility of the department of family practice. Similarly, privileges recommended by the department of obstetrics-gynecology shall be the responsibility of the department of obstetrics-gynecology. When privileges are recommended jointly by the departments of family practice and obstetrics-gynecology, they shall be the joint responsibility of the two departments.

Copyright © 1998 by the American Academy of Family Physicians.
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