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Am Fam Physician. 1998;58(1):275-277

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

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