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

   Normal female growth and development, and variants

   Appropriate history and physical examination for all age groups

   Gynecology

   Disease prevention/health promotion and periodic health evaluation

   Physiology of menstruation

   Abnormal uterine bleeding

   Gynecologic problems of children

   Infections and diseases of the female reproductive and urinary systems

   Breast health and diseases of the breast

   Sexual assault

   Domestic violence

   Trauma to the reproductive system

   Pelvic pain

   Benign and malignant neoplasms of the female reproductive system

   Menopause and geriatric gynecology

   Indications for surgical intervention

   Cervical lesions and abnormal cytology

   Ectopic pregnancy

   Obstetrics

   Prepregnancy planning and counseling

   Prenatal care, including risk assessment

   Labor and delivery

   Postpartum care

   Care of the normal newborn

   Common neonatal problems

   Analgesia and anesthesia for labor and delivery

   Indications for cesarean delivery

   Obstetric complications and emergencies

   Lactation

   Family life education

   Family planning

   Fertility problems

   Interconceptional care

   Family and sexual counseling

   Consultation and referral

   The role of the obstetrician, gynecologist and subspecialist

   Women's health care delivery systems

   Regionalized perinatal care for high-risk pregnancies

   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.

   Gynecology

   Appropriate screening examination of the female, including breast examination

   Obtaining vaginal and cervical cytology

   Colposcopy

   Cervical biopsy, polypectomy

   Endometrial biopsy

   Culdocentesis

   Cryosurgery/cautery for benign disease

   Microscopic diagnosis of urine and vaginal smears

   Bartholin duct cyst drainage or marsupialization

   Dilation and curettage for incomplete abortion

   Family planning and contraception

   Oral contraceptive counseling and prescribing

   Intrauterine contraceptive device counseling, insertion and removal

   Diaphragm fitting and counseling

   Insertion and removal of subcutaneous contraceptive implants and counseling

   Injectable long-term contraceptives and counseling

3. Pregnancy

   Prepregnancy evaluation

   Initial pregnancy visit

   Risk assessment

   History, physical examination, laboratory monitoring, and counseling throughout pregnancy

   Noninvasive evaluation of fetal gestational age and fetoplacental adequacy, including limited obstetric ultrasound examination

   Management of labor

   Pudendal and local block anesthesia

   Fetal assessment, antepartum and intrapartum, including limited obstetric ultrasound examination

   Induction of labor

   Internal fetal monitoring

   Normal cephalic delivery including use of vacuum extraction and outlet forceps

   Episiotomy and repair, including third-degree lacerations

   Management of common intrapartum problems (e.g., hypertension, mild pre-eclampsia, fever, infection, nonreassuring fetal status, unanticipated shoulder dystocia, manual removal of placenta)

   Exploration of vagina, cervix, uterus

   Emergency breech delivery

   Neonatal resuscitation

   Management of common postpartum problems (e.g., hemorrhage, endometritis)

   First-assist at cesarean delivery

   Vaginal delivery after previous cesarean delivery

4. Surgery

   Assist at common major surgical procedures

1. 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.

   Gynecology

   Loop electrosurgical excision procedures

   Family planning and contraception

   Voluntary interruption of pregnancy up to 10 weeks of gestation

   Pregnancy

   Ultrasound-guided amniocentesis, mid- and third-trimester

   Conduction anesthesia and analgesia (not routinely taught by obstetrician-gynecologists)

   Management of preterm labor

   Management of multiple gestation

   Management of breech delivery

   External cephalic version

   Amnioinfusion

   Use of low forceps

   Fourth-degree lacerations

   Severe pre-eclampsia

   Performance of cesarean delivery

   Management of complications of vaginal birth after previous cesarean delivery

   Surgery

   Tubal ligation, postpartum and with cesarean delivery