Scope Of Practice And Clinical Responsibilities - Ob-Gyn

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Health Regulation DepartmentScope of Practice and Clinical ResponsibilitiesObstetrics/Gynecology2016

Table of ContentsAcknowledgment . 31.Introduction . 42.DHA licensing titles . 43.Permitted health facilities for practice . 54.General scope . 55.Areas of clinical expertise . 75.1Antenatal care . 75.2Early pregnancy care. 85.3Maternal medicine . 85.4Management of labour . 95.5Management of delivery and intrapartum complications . 105.6Postpartum care. 115.7Fetal medicine . 115.8Gynecological care. 125.9Urogynecology and pelvic care . 135.10Surgical procedures and postoperative care . 145.11Sexual and reproductive health . 155.12Termination of pregnancy . 165.13Female sterilization and reproduction . 185.14Infertility . 185.15Gynecological oncology . 206.References. 21Scope of Practice - Obstetrics and GynecologyPage 2 of 23Ref. No. HRD/HRS/PRU/029

AcknowledgmentDubai Health Authority (DHA) is pleased to present the scope of practice and clinicalresponsibilities of Obstetrics and Gynecology, which represents a milestone towards fulfillingthe DHA Strategic Objective to “Ensure continuous development of health and medicalprofessionals and attract the highly qualified”. This document places an emphasis on theprocedures that can be performed by a licensed Obstetrics and Gynecology in the Emirate ofDubai.This document was developed by the Health Regulation Department (HRD) in collaborationwith Subject Matter Experts (SMEs) whose contributions have been invaluable. HRD wouldlike to gratefully acknowledge those professionals and to thank them for their dedication toquality in healthcare and their commitment in undertaking such a complex task.Health Regulation DepartmentDubai Health AuthorityScope of Practice - Obstetrics and GynecologyPage 3 of 23Ref. No. HRD/HRS/PRU/029

1. Introduction1.1Obstetrics and gynecology (Ob/Gyn) is a discipline dedicated to the broad,integrated medical and surgical care of women's health throughout their lifespan.1.2The combined discipline of obstetrics and gynecology requires extensive study andunderstanding of reproductive physiology, including the physiologic, pathologic,social, cultural, environmental and genetic factors that influence disease in women.1.3Obstetrics and gynecology encompasses preventive health, reproductive health,gynecological surgery, maternal and fetal care and for women of all ages.1.4Preventive counseling and health education are essential and integral parts of thepractice of Ob/Gyn as they advance the individual and community-based health ofwomen of all ages.1.5This document defines the skills, activities and expertise that fall within theObstetrics and gynecology scope of practice. However, for practices/activities otherthan those mentioned in this document, the Ob/Gyn shall seek an approval from theHRD at DHA prior to performing the practice.2. DHA licensing titlesAs per the healthcare Professionals Qualification Requirements (PQR), DHA issuesObstetrics and gynecology title under the following licensing titles:2.1Consultant title is issued to physicians who have completed basic medical degreeand approved specialty degree listed under Tier 1 and 2 with the required clinicalexperience.2.2Specialist title is issued to physicians who have completed basic medical degree andapproved specialty degree with the required clinical experience.2.3Specialist under supervision title was issued by DHA to physicians who havetrained in a specialty degree but did not meet the required clinical experience as perthe PQR to obtain a full Specialist title. DHA is not issuing this title anymore andholders of this title will be given a grace period until January, 2017 to obtainSpecialist title.i. Scope of practice of specialist under supervision physicians is similarto Specialist Ob/Gyn; but shall practice under consultant/specialistScope of Practice - Obstetrics and GynecologyPage 4 of 23Ref. No. HRD/HRS/PRU/029

supervision in the same health facility at a ratio of 2:1 (two specialistunder supervision to one consultant/specialist)3. Permitted health facilities for practiceObstetrics and gynecologist, licensed by DHA, can practice in the below health facilities:3.1Hospitals3.2Day surgical centers3.3Outpatient care facilities including polyclinics or specialty clinics3.4Fertility centers4. General scope4.1Obstetricians and gynecologist shall understand and demonstrate the appropriateknowledge, skills and attitudes to assess women by means of clinical history takingand physical examination, as:4.1.1Neck and chest examination4.1.2Breast examination4.1.3Abdominal and lower limb examination; for both pregnant and non-pregnantwomen4.1.4Vaginal examination4.1.5Microbiology swabs for the throat, vagina, cervix, urethra, rectum, andcervical smear4.2Within their skills, competencies and experience, licensed Ob/Gyn shall:4.2.1Assure that their medical practice is in adherence with internationally andnationally recognized guidelines for management of any Ob/Gyn relatedpathology.4.2.2Provide continuing and comprehensive medical care, health maintenance,and preventive services to women, relatives, and colleagues in a variety ofclinical situations.4.2.3Demonstrate diagnostic and therapeutic skills for effective patient care byusing evidence based medical practices.4.2.4Demonstrate effective consultation with respect to patient care, culture andeducation.Scope of Practice - Obstetrics and GynecologyPage 5 of 23Ref. No. HRD/HRS/PRU/029

4.2.5Obtain relevant history from patients and keep accurate and adequate patientrecords.4.2.6Recognize their own practice limitations and seek consultation with otherhealthcare professionals, when necessary, to provide optimal patient care.4.2.7Demonstrate an understanding of medico-legal issues related to thespecialty.4.2.8Establish therapeutic relationships with patients/families.4.2.9Function as a counsellor and advocate to effectively improve health ofpatients, families and communities.4.2.10 Diagnose, treat and manage diseases of the female reproductive organs,order and interpret laboratory and diagnostic tests and prescribe medicationsas per the DHA local regulations and Unites Arab Emirates (UAE) Federallaws.4.2.10.1 Ob/Gyn holding DHA “Consultant” title can prescribe controlleddrugs-CD (CD-A) up to (30) days only, and semi controlled drugsSCD (CD-B) up to (90) days in total. In this case, they have toprescribe CD-B initially for (30) days with 2 refills, to be dispensedat the end of the previous (30) days each refill.4.2.10.2 Ob/Gyn holding DHA “Specialist” title can prescribe controlleddrugs-CD (CD-A) up to (15) days only, and semi controlled drugsSCD (CD-B) up to (60) days in total. In this case, they have toprescribe CD-B initially for (30) days with one refill of another(30) days, to be dispensed at the end of the previous (30) days.4.2.11 Understand and abide to the UAE Federal laws and DHA regulations relatedto termination of pregnancy, female sterilization/regulating reproduction,sexually transmitted diseases (STDs), consent, child protection, sexualoffences and medical research and experiments.4.2.12 Demonstrate effective referral services, especially in infertility cases, withrespect to patient care and effectively contribute to other interdisciplinaryteam activities.4.2.13 Deliver highest quality care with integrity, honesty and compassion.Scope of Practice - Obstetrics and GynecologyPage 6 of 23Ref. No. HRD/HRS/PRU/029

5. Areas of clinical expertise5.1Antenatal care5.1.1Take obstetric history and demonstrate the knowledge of:5.1.1.1Preconception care5.1.1.2Placental abnormalities and diseases5.1.1.3Immunology and immunological disorders affecting pregnancy5.1.1.4Drug and alcohol misuse5.1.2Undertake pregnant and non-pregnant abdominal examination.5.1.3Manage antenatal complications, as:5.1.3.1Miscarriage and fetal death5.1.3.2Growth restriction5.1.3.3Abnormal placentation5.1.3.4Mode of delivery after caesarean section5.1.3.5Antepartum hemorrhage5.1.3.6Malpresentation5.1.3.7Red cell/platelet alloimmunisation5.1.3.8Preterm pre-labour rupture of the fetal membranes5.1.3.9Reduced fetal movements5.1.3.10 Prolonged pregnancy5.1.3.11 Drug and alcohol abuse in pregnancy5.1.3.12 Infections during pregnancy5.1.4Assess fetal wellbeing by interpretation of cardiotocography (CTG).5.1.5Perform, interpret and report the fetal scans.5.1.6Perform external cephalic version (ECV) and cervical cerclage.5.1.7Counsel the patients about:5.1.7.1Screening for Down syndrome5.1.7.2Genetic diseases5.1.7.3Fetal abnormalities5.1.7.4Hemolytic diseases5.1.7.5Infections5.1.7.6Mode of deliveryScope of Practice - Obstetrics and GynecologyPage 7 of 23Ref. No. HRD/HRS/PRU/029

5.1.7.75.1.8Female sterilization for medical indicationsRecognize any domestic violence and make relevant referral appropriately asper the UAE laws.5.2Early pregnancy care5.2.1Understand the epidemiology, etiology, pathogenesis and clinical features ofearly pregnancy loss/miscarriage.5.2.2Perform clinical assessment of miscarriage and ectopic pregnancy.5.2.3Perform biochemical assessment of early pregnancy.5.2.4Perform surgical, minimal access surgery and non-surgical management ofmiscarriage and ectopic by appropriate techniques.5.2.5Recognize the need for appropriate referral for more complex therapeuticneeds or detailed evaluation with ultrasound or other imaging techniques.5.3Maternal medicine5.3.1Diagnose, investigate and manage maternal complications due to pregnancy,including, but not limited to, and refer to specialists whenever needed:5.3.1.1Acute abdominal pain5.3.1.2Asthma and other respiratory diseases5.3.1.3Coagulation .1.6Essential hypertension5.3.1.7Gestational diabetes5.3.1.8Infectious diseases5.3.1.9Inflammatory bowel disease5.3.1.10 Pregnancy with type 1 diabetes5.3.1.11 Intercurrent infection5.3.1.12 Kidney disease5.3.1.13 Liver disease5.3.1.14 Maternal hemoglobinopathy5.3.1.15 Neoplasia and malignanciesScope of Practice - Obstetrics and GynecologyPage 8 of 23Ref. No. HRD/HRS/PRU/029

5.3.1.16 Preeclampsia5.3.1.17 Pregnancy-induced hypertension5.3.1.18 Psychological disorders5.3.1.19 Thromboembolism5.4Management of labour5.4.1Understand that labours shall be conducted only in general hospitals orspecialized hospitals with Ob/Gyn specialty.5.4.2Understand and demonstrate appropriate knowledge related to labour,including:5.4.2.1Mechanisms of normal labour and delivery5.4.2.2Induction and augmentation of labour5.4.2.3Drugs acting upon the myometrium5.4.2.4Structure and use of partograms5.4.2.5Regional anesthesia, analgesia and sedation5.4.2.6Monitoring fetal wellbeing in labour5.4.2.7Obstetric emergencies/ maternal collapse/ hemorrhage/ shoulderdystocia/uterine inversion and cord prolapse5.4.2.85.4.3Pre-term labour/premature rupture of membranesAbility to effectively manage:5.4.3.1In-utero transfer for premature delivery5.4.3.2Intrauterine fetal death (IUFD) with respect to legal regulations5.4.3.3Obstetric hemorrhage5.4.3.4Severe pre-eclampsia/eclampsia5.4.3.5Obstetric collapse5.4.3.6Induction of labour5.4.3.7Delay in labour5.4.3.8Abnormal labour5.4.3.9Labour after a previous lower segment caesarean section5.4.3.10 Preterm labour5.4.4Coordinate and run labour ward by prioritizing labour cases and supervisingthe workload and problems in the labour ward.Scope of Practice - Obstetrics and GynecologyPage 9 of 23Ref. No. HRD/HRS/PRU/029

5.4.5Evaluate clinical risks for abnormal labour.5.4.6Interpret a CTG and perform fetal blood sampling when indicated.5.4.7Order and interpret diagnostic tests as CT or MRI scan, lumbar puncture andx-rays to assess adverse effects of emergency conditions.5.4.8Prescribe blood products and deal with women who decline blood or bloodproducts.5.4.9Advise on pain relief.5.4.10 Removal of cervical suture.5.5Management of delivery and intrapartum complications5.5.15.5.2Understand and demonstrate appropriate labour knowledge, including:5.5.1.1Normal, operative and complex vaginal delivery5.5.1.2Retained placenta5.5.1.3Caesarean section5.5.1.4General and regional anesthesiaManage intrapartum complications as, failure to progress in labour, nonreassuring fetal status in labour, genital tract trauma and caesarean section.5.5.3Ability to effectively manage:5.5.3.1Acute emergency caesarean section5.5.3.2Caesarean section with placenta praevia5.5.3.3Caesarean section with sterilization5.5.3.4Cord prolapse5.5.3.5Delivery with fetal malpresentation5.5.3.6Forceps delivery without rotation5.5.3.7Normal delivery, episiotomy repair and repair of third and fourthdegree perineal repair with referral to colorectal surgeon whennecessary5.5.3.8Previously undiagnosed breech5.5.3.9Recognition of mal-presentation5.5.3.10 Repeat caesarean section5.5.3.11 Retained placenta5.5.3.12 Shoulder dystociaScope of Practice - Obstetrics and GynecologyPage 10 of 23Ref. No. HRD/HRS/PRU/029

5.5.3.13 Uncomplicated caesarean section5.5.3.14 Uterine rupture5.5.3.15 Vacuum extraction5.5.3.16 Vaginal breech delivery5.5.3.17 Vaginal breech delivery including second twin5.5.3.18 Vaginal delivery of twins5.6Postpartum care5.6.1Understand and demonstrate appropriate knowledge, skills and attitudes inrelation to postpartum and neonatal problems, including:5.75.6.1.1The normal puerperium, including contraception5.6.1.2Breast problems5.6.1.3Perineal and vaginal tears5.6.1.4Damage to rectum and anal sphincters5.6.1.5Postpartum sepsis5.6.1.6Primary, secondary and other postpartum hemorrhage5.6.1.7Acute maternal collapse5.6.1.8Puerperal psychiatric disorders5.6.2Have the knowledge of normal and abnormal postpartum period.5.6.3Demonstrate skills in acute resuscitation.Fetal medicine5.7.1Understand and demonstrate the appropriate knowledge of:5.7.1.1Fetal growth stages.5.7.1.2Fetal normal anatomy.5.7.1.3Principles of chromosomal and genetic disorders.5.7.1.4Performing non-invasive prenatal diagnosis: ultrasound andbiochemical markers5.7.1.5Performing invasive procedures as chorionic villus sampling,amniocentesis, placentesis and cordocentesis only after having theskills to perform the procedures as Fellowship in Fetal Medicineor any equivalent certificate along with hands-on training.Scope of Practice - Obstetrics and GynecologyPage 11 of 23Ref. No. HRD/HRS/PRU/029

5.7.1.6Principles of obstetric ultrasonography.5.7.1.7Principles of prenatal counselling for fetal chromosomal, geneticand congenital anomalies.5.7.1.8Principles of fetal wellbeing by fetal growth assessment,biophysical profile and vascular doppler studies. Perform andinterpret a fetal blood sample as per the hospital policies.5.7.2Diagnose, investigate and manage fetal complications due to, but notlimited to:5.85.7.2.1Intrauterine growth restriction and fetal macrosomia5.7.2.2Congenital anomalies5.7.2.3Congenital infections5.7.2.4Fetal anemia and thrombocytopenia5.7.2.5Multiple pregnancy and fetal reduction in multiple pregnancy5.7.2.6Oligohydramnios and polyhydramnios5.7.2.7Twin to twin transfusion syndrome5.7.2.8Fetal hydrops5.7.2.9Intrauterine fetal deathGynecological care5.8.1Understand and demonstrate appropriate knowledge, skills and attitudes inrelation to common gynecological disorders.5.8.2Understand pediatric and adolescent gynecological disorders.5.8.3Understand epidemiology, etiology, biological behavior, pathophysiology,clinical characteristics, prognostic features and the management of:5.8.3.1Benign conditions of the genital tract5.8.3.2Congenital and acquired abnormalities of the genital tract5.8.3.3Emergency gynecology5.8.3.4Endocrine disorders5.8.3.5Menstrual disorders5.8.3.6Pelvic pain and endometriosis5.8.3.7Problems of the climacteric5.8.3.8PubertyScope of Practice - Obstetrics and GynecologyPage 12 of 23Ref. No. HRD/HRS/PRU/029

5.8.3.95.8.4Vaginal dischargeUnderstand the anatomy and physiology of the vulva, take the history andcounsel patient on the use of topical steroids/emollients.5.8.5Perform endometrial assessment/biopsy, diagnostic hysteroscopy andlaparoscopy.5.8.6Recognize the need for appropriate referral for more complex or detailedevaluation with ultrasound or other imaging techniques.5.9Urogynecology and pelvic care5.9.1Understand the anatomy, physiology and pathophysiology of pelvic floorand urinary tract.5.9.2Understand the epidemiology, etiology, characteristics and prognosis of,but not limited to:5.9.35.9.2.1Urinary and fecal incontinence5.9.2.2Urogenital prolapse5.9.2.3Urinary infections5.9.2.4Lower urinary tract disorders5.9.2.5Urinary disorders associated with other conditionsInitiate lower and upper urinary tract, neurology, pelvic floor and colorectalinvestigations along with understanding and interpreting results.5.9.4Take urogynecological history and carry out appropriate general, pelvicfloor and neurological examination.5.9.5Assess pelvic floor strength, insert catheters and fit/change pessaries.5.9.6Assess and manage uterovaginal prolapse as pelvic organ prolapse andvaginal hysterectomy.5.9.7Treat acute bladder voiding disorder5.9.8Counsel and plan initial management of overactive bladder symptoms andstress urinary incontinence.5.9.9Perform and interpret urodynamic assessment.5.9.10 Perform surgeries for urinary incontinence after maintain the required skillsand knowledge or recognize the need for appropriate referral to specialistsfor more specialized management.Scope of Practice - Obstetrics and GynecologyPage 13 of 23Ref. No. HRD/HRS/PRU/029

5.10 Surgical procedures and postoperative care5.10.1 Demonstrate the knowledge of relevant basic sciences along with theknowledge of instruments and sutures.5.10.2 Understand and demonstrate appropriate knowledge in relation to basicsurgical skills.5.10.3 Maintain the required skills to be able to proficiently perform:5.10.3.1 Correction of vulval and vaginal congenital or acquiredabnormalities.5.10.3.2 Diagnostic and operative laparoscopy5.10.3.3 Diagnostic hysteroscopy (including end

Scope of Practice - Obstetrics and Gynecology Page 4 of 23 Ref. No. HRD/HRS/PRU/029 1. Introduction 1.1 Obstetrics and gynecology (Ob/Gyn) is a discipline dedicated to the broad, integrated medical and surgical care of women's health throughout their lifespan.

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