Most obstetricians prefer to see their patients early in pregnancy, two or three weeks after the first menstrual period is missed. Many women look forward to this first interview with unnecessary dread. Perhaps a friend with previous experience has told them that it is a most embarrassing examination, and such questions! The patient is apt to forget that the doctor has examined literally thousands of women, and in the course of this experience has learned to impersonalize his attitude toward his patients.
Realizing that this first session is likely to be awkward for his patient, the doctor tries to put her at ease by social pleasantries before taking down a careful and thorough history. His questions are designed to construct a complete surgical and medical background of the patient from birth to the present time, with emphasis on any diseases which may have left after-effects. Age, length of marriage, and occupation are sought. The date of the last menses and the previous use of contraceptives are noted. The months or years it took to achieve the current pregnancy are recorded. The questions now turn to the family and the possible presence of any disease with familial tendencies; also they concern the existence of twins in the family tree—alarming suggestion! The husband then shares the limelight for one brief, casual moment while his state of health, his height, and his weight are noted. Each previous pregnancy, if there were any, is successively reviewed; date, duration, length of labor, type of delivery, size of infant, and several other facts are included. Finally the data concerning the present pregnancy are recorded, the symptoms and complaints. The patient’s nonpregnant weight is asked and the history brought to a close, much to the relief of the patient, who has become very confused trying to remember whether she was five or seven when stricken with measles, or if old age was really the cause of her maternal grandmother’s demise.
The Physical Examination
By now the patient and doctor are well acquainted and on friendly terms. The tension has lessened; the ordeal is not proving so dreadful as expected; and the stiffly starched nurse, who is summoned to conduct the patient to the dressing-room, is pleasant and reassuring. The patient undresses completely and, after voiding a specimen of urine, is initiated by the nurse into the art of wrapping herself in a sheet. After being weighed and then covered by a breast towel and the unfurled sheet, she lies on the hard, uncomfortable examin-ing-table. The doctor enters, and after a few pleasant words the examination begins.
At the first visit the obstetrician examines the woman completely from top to toe. It is essential that he determine the exact physical condition of his patient, so that he may judge her ability to withstand the strain of pregnancy and labor. In addition to a general physical examination, including height, weight, and blood pressure, several laboratory procedures are included: tests of urine and hemoglobin (the red coloring matter in the blood), and serology. In most states a test for syphilis is obligatory for all pregnant women, even though the premarital one was negative. The blood is drawn by needle and syringe from a vein on the inner aspect of the arm where the forearm and upper arm join. Most physicians also determine the Rh of the blood on the same specimen— that is, whether Rh positive or Rh negative. At the same time the blood is grouped into one of the four blood groups A, B, AB, or O, in anticipation of possible transfusion at delivery. After the general physical survey, the obstetrician performs a vaginal examination to map out the form, size, and consistency of the uterus; to determine the condition of the ovaries and Fallopian tubes; and to make certain that the pregnancy is situated in the uterus and not in the tube (tubal pregnancy). The measurement of the pelvis, the bony canal through which the baby must pass, is a most important part of this first examination. It is an obvious rule in mechanics that in order to determine if a rigid body can pass through a rigid tube, both the body and the tube must be measured. The physician feels carefully the bony architecture of the pelvis and takes two standard measurements, one external and one vaginal; from these data he approximates its normalcy.
Subsequent Prenatal Visits
During the first five months the obstetrician sees his patient at monthly intervals, during the next two months every three weeks, and during the final two months at least every week or two. Naturally, if any complication arises, he may see her more often.
At these subsequent visits the physician discusses any new symptoms which the patient has noticed, and he takes the blood pressure, weighs her, and examines the urine. He then gives directions for the ensuing few weeks and prescribes drugs when necessary. At almost every visit, in addition, the doctor palpates the abdomen to find out if theis growing at a normal rate. When the pregnancy is far enough advanced he listens to the fetal heart and determines the fetus’s position.
The Relatively Low Scale of Obstetric Fees
In most communities an obstetrician’s fee includes all’ charges and covers prenatal supervision, delivery, and aftercare for the six weeks following childbirth. This is advantageous to both patient and doctor; the obstetrician can see his patient whenever necessary without the deterrent of expense to her. In general, obstetric fees are disproportionately low considering the great amount of time the doctor invests in each case. A surgeon can charge a goodly amount for a simple appendectomy, or the same obstetrician-gynecologist can even make a considerable charge for the removal of an ovary or a uterus, and the bill is cheerfully paid. These surgeons spend half an hour making the diagnosis and three-quarters of an hour operating, and then make six post-operative calls of ten minutes each, giving a total of a little more than two hours of their time. If the obstetrician attempts to charge an equal amount for his months of care, he meets stern resistance. Yet the obstetrician spends three-quarters of an hour at the first visit, fifteen minutes at each of the ten prenatal visits, ten hours on the average during labor; afterward he calls daily at the hospital; he gives the final office examination a month after delivery. This makes a total of sixteen hours. It is difficult to know why this attitude exists toward obstetrical fees. Perhaps since the general practitioner still does the majority of deliveries, the layman feels that the obstetric specialist is not entitled to a pay scale commensurate with other surgical branches.