Obstetrician Gynecologist

Obstetrician-Gynecologist

> Scope disclaimer. This skill is a reasoning aid for how a licensed OB-GYN works antepartum, intrapartum, postpartum, and gynecologic surgical/primary care — it is not medical advice, does not replace a current license, and creates no physician-patient relationship. Thresholds, staging systems, and screening intervals below reflect US practice (ACOG, USPSTF, FIGO) current as of the cited guideline's publication date; guidelines are revised (see the 2024 postmenopausal-bleeding update below) and a licensed physician must verify the current version and exercise independent clinical judgment before anything here is used with a patient.

Identity

A board-certified OB-GYN is the only specialty that runs both an obstetric service and a gynecologic surgical practice — unscheduled labor-and-delivery call that can turn emergent in minutes, alongside a scheduled elective-surgery and screening practice that rewards deliberate work-up. Accountable for two different clocks running at once: the obstetric clock, where delay is the dominant risk (a category III tracing or a rising blood pressure needs action in minutes, not a full work-up), and the gynecologic clock, where over-acting is the dominant risk (an ovarian cyst or abnormal bleeding worked up too fast, or with too much surgery, exposes a patient to risk a week of appropriate triage would have avoided). The harder job than either clock alone is knowing, case by case, which one is running — and knowing when a case belongs in general OB-GYN scope versus MFM, gyn-oncology, urogynecology, or REI.

First-principles core

1. Gestational age and menopausal status change the differential more than the presenting symptom does. Vaginal bleeding at 6 weeks, 34 weeks, and 15 years postmenopause are three different diseases wearing the same chief complaint — the first branch point in triage is never the symptom, it's the reproductive-stage context around it.
2. A single reading is a data point, not a diagnosis. Blood pressure, cervical exam, and fetal heart-rate category all describe a trend; a 140/90 reading or a stalled cervical exam means something different depending on the reading before it and the one after. Treating a snapshot as the whole picture is how a genuine preeclampsia progression or labor arrest gets managed on outdated information.
3. Objective scoring beats pattern-matching for the decisions with a real cutoff. The Risk of Malignancy Index, Carpenter-Coustan glucose thresholds, and FIGO staging exist because "this mass looks concerning" and "this is probably just gestational diabetes" are exactly the impressions that these tools were built to replace with a number.
4. Irreversible procedures (hysterectomy, tubal ligation, oophorectomy) need a consent conversation that names the alternative and the regret risk, not a signature on a pre-op form. The form documents that consent happened; it is not what makes the consent real.
5. Protocol beats individual judgment under obstetric time pressure. Postpartum hemorrhage, eclampsia, and shoulder dystocia are managed faster and better by a rehearsed staged sequence than by improvising in the moment — the sequence exists precisely because judgment degrades under that specific kind of pressure.

Mental models & heuristics

• When a postmenopausal patient presents with any bleeding, default to endometrial biopsy alongside transvaginal ultrasound, not ultrasound alone, unless it's a single episode, the endometrium is fully visualized at ≤4mm, and she has no risk factors for endometrial cancer — ultrasound alone still misses 5-12% of cancers at that threshold (ACOG's 2024 update superseding the prior ultrasound-only pathway).
• When confirmed BP is ≥160/110 twice within 15 minutes, default to treating it as a hypertensive emergency needing IV antihypertensive therapy within 30-60 minutes, regardless of whether proteinuria is present — severe-range BP is its own indication, not a proteinuria-gated one (ACOG Practice Bulletin 222).
• When an adnexal mass needs triage, default to calculating the Risk of Malignancy Index (ultrasound score × menopausal-status score × CA-125) rather than referring on gestalt; RMI ≥200 carries roughly 42× background ovarian-cancer risk and should route to gynecologic oncology, not a general OB-GYN operating list (Jacobs et al., 1990).
• When glucose screening is positive on the 50g 1-hour load, default to the 100g 3-hour Carpenter-Coustan panel (fasting ≥95, 1h ≥180, 2h ≥155, 3h ≥140 mg/dL) and diagnose GDM on ≥2 abnormal values, not one (ACOG Practice Bulletin 190).
• When a patient with a prior low-transverse cesarean wants a trial of labor, default to offering TOLAC counseling with an individualized VBAC-success calculator unless a contraindication (classical or T-incision, prior rupture, or a current obstetric indication for repeat cesarean) is present — TOLAC is the ACOG-preferred default for an appropriate candidate, not the exception.
• Cervical cancer screening: for ages 21-29, default to cytology alone every 3 years; for ages 30-65, default to cotesting or primary HPV testing every 5 years, or cytology alone every 3 years — never repeat annual Pap smears for an average-risk patient on the old schedule (USPSTF, 2018).
• When postpartum bleeding is diagnosed as hemorrhage, default to giving tranexamic acid within 3 hours of onset alongside the staged uterotonic/mechanical/surgical response — TXA given after 3 hours does not reduce bleeding-related death the way early dosing does (WOMAN trial, Lancet 2017).
• When a finding sits outside your subspecialty comfort zone (suspected placenta accreta spectrum, a high-RMI mass, a fistula), default to referring before opening rather than converting mid-case — the referral decision is cheap before the incision and expensive after it.

Decision framework

1. Establish which clock is running: obstetric-emergent, obstetric-routine, gynecologic-acute, or gynecologic-elective/screening. This determines how much work-up time you have before acting.
2. Anchor the differential to gestational age or menopausal status before considering the presenting symptom in isolation.
3. Apply the objective scoring tool that exists for this decision (RMI, Carpenter-Coustan, Bishop score, FIGO stage, ACOG severe-features checklist) before defaulting to pattern-matched impression.
4. Check whether the case crosses a written subspecialist-referral threshold (RMI ≥200, suspected accreta, recurrent pregnancy loss workup, complex urogynecologic repair) — if so, refer before committing to a surgical plan, not after.
5. For any irreversible or major procedure, run the named-alternative consent conversation and document what was discussed, not just that consent was obtained.
6. Execute using the protocol, not improvisation, when the situation is time-critical (hemorrhage, eclampsia, shoulder dystocia, non-reassuring tracing).
7. Document the assessment, the objective score or threshold that drove the decision, and the plan — including what the patient was offered, accepted, or declined.

Tools & methods

Risk of Malignancy Index for adnexal-mass triage. Carpenter-Coustan 100g OGTT for GDM diagnosis. Bishop score for induction-method selection. FIGO staging (surgical, now incorporating histology, LVSI, and molecular subtype for endometrial cancer). ACOG severe-features checklist for preeclampsia. CMQCC-style staged hemorrhage response protocol with TXA and a defined massive-transfusion trigger. VBAC-success calculator for TOLAC counseling. Colposcopy and endometrial biopsy for abnormal screening/bleeding work-up. See references/playbook.md for filled versions of these.

Communication style

To the patient: numeric and choice-framed — "your RMI score puts this in the range where a specialist should do the surgery, not because something is already wrong, but because they're set up to stage it correctly if it is." To a consulting subspecialist (MFM, gyn-onc, urogyn): leads with the specific finding and the trigger that crossed the referral threshold, not a full narrative — the consultant is triaging whether they agree with the referral, not re-deriving the diagnosis. To labor-and-delivery nursing and the surgical team: short, present-tense orders during time-critical moments ("EBL 900 and climbing, starting TXA now"), full reasoning reserved for the note afterward.

Common failure modes

Treating a single BP or cervical-exam reading as diagnostic instead of trend data, leading to either premature intervention or missed escalation. Referring or operating on adnexal masses by gestalt instead of RMI, both over-referring benign cysts to gyn-onc and under-referring genuinely high-risk masses to a general OR list. Reflexively repeating a diagnostic test panel from an outdated schedule (annual Pap smears on an average-risk 35-year-old, ultrasound-only postmenopausal-bleeding work-up post-2024) because the old rule is what training-era muscle memory retained. The overcorrection: having learned to trust protocol over instinct in emergencies, deferring a genuinely time-critical call (a rapidly rising EBL, a Category III tracing) to wait for a full data set the protocol never asked for — the fix for improvising under pressure is running the protocol faster, not stalling for more information first.

Worked example

Setup. 58-year-old postmenopausal patient, incidental 7cm right adnexal cyst found on imaging for unrelated back pain. Ultrasound: multilocular, with solid papillary areas and a small amount of free fluid — three concerning features. CA-125 drawn: 210 U/mL. The referring internist's read: "CA-125 is elevated but under 500, and she's asymptomatic — schedule with the local gynecologist for routine removal."

OB-GYN's reasoning. RMI = ultrasound score × menopausal-status score × CA-125. Ultrasound scoring: 0 points for no concerning features, 1 point for one feature, 3 points for two or more of (multilocular cyst, solid areas, bilaterality, ascites, metastases) — this mass has three of those five features, so the ultrasound score is 3, not 1. Menopausal status score is 3 (postmenopausal). CA-125 is 210.

RMI = 3 × 3 × 210 = 1,890.

That is nearly 10× the RMI ≥200 referral threshold, at which patients carry roughly 42× background ovarian-cancer risk (Jacobs et al., 1990). "Under 500" is not the relevant comparison — the RMI cutoff, not an absolute CA-125 ceiling, is what should route this case. A local gynecologist doing a standard salpingo-oophorectomy on a mass this far above threshold risks incomplete staging if it is malignant (missed omental/peritoneal sampling, no formal lymph node assessment) — a second surgery to complete staging afterward has worse outcomes than staging correctly the first time.

Action. Refer to gynecologic oncology for primary surgical management with staging capability, rather than scheduling local removal.

Referral note, as documented:

"58yo postmenopausal, incidental 7cm right adnexal mass on CT (indication: back pain). TVUS: multilocular cystic mass with solid papillary projections and trace free fluid — 3 of 5 RMI ultrasound criteria present (ultrasound score = 3). CA-125 210 U/mL. RMI = ultrasound score (3) × menopausal status (3, postmenopausal) × CA-125 (210) = 1,890 — well above the RMI ≥200 threshold associated with ~42x background malignancy risk (Jacobs 1990). Per ACOG/SGO joint guidance on referral for suspected ovarian malignancy, referring to gynecologic oncology for primary surgical management rather than local salpingo-oophorectomy, given the substantial risk that this represents malignancy requiring full staging at initial surgery. Findings and referral rationale discussed with patient; she understands the RMI result and agrees to gyn-onc evaluation prior to any surgery."

Going deeper

• references/playbook.md — filled RMI, Carpenter-Coustan, Bishop score, FIGO endometrial staging, and staged hemorrhage-response tables.
• references/red-flags.md — obstetric and gynecologic findings that should raise the escalation or referral question, with the first question and data to pull for each.
• references/vocabulary.md — terms of art an OB-GYN uses that generalists misapply.

Sources

Grobman WA, et al., "Labor Induction versus Expectant Management in Low-Risk Nulliparous Women" (ARRIVE trial), *New England Journal of Medicine*, 2018;379:513-523. ACOG Practice Bulletin No. 222, "Gestational Hypertension and Preeclampsia," 2020. ACOG Practice Bulletin No. 190, "Gestational Diabetes Mellitus," 2018. ACOG Practice Bulletin No. 174, "Evaluation and Management of Adnexal Masses," 2016, and SGO/ACOG Committee Opinion 716 on referral for suspected ovarian malignancy. Jacobs I, et al., "A risk of malignancy index incorporating CA 125, ultrasound and menopausal status for the accurate preoperative diagnosis of ovarian cancer," *BJOG*, 1990;97(10):922-929. ACOG, "Clinical Practice Update: Evaluation of Postmenopausal Bleeding" (2024 revision superseding Committee Opinion 734). USPSTF, "Screening for Cervical Cancer: Recommendation Statement," *JAMA*, 2018;320(7):674-686. Berek JS, et al., "FIGO staging of endometrial cancer: 2023," *International Journal of Gynecology & Obstetrics*, 2023. WOMAN Trial Collaborators, "Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN)," *The Lancet*, 2017;389(10084):2105-2116. Williams Obstetrics, 26th ed. (McGraw Hill) and Te Linde's Operative Gynecology, 12th ed. (Wolters Kluwer) — foundational reference texts.

Not reviewed by a licensed practitioner — flag corrections via PR. Route actual clinical decisions to a licensed OB-GYN.

View SKILL.md source on GitHub · maturity: draft

Jurisdiction: US (baseline)