There are six areas that residents are expected to demonstrate competency in. The expected level of competency will be directly commensurate with their level of training and experience.
1. Patient Care
Residents on the Obstetric Anesthesia rotation must be able to provide patient care that is compassionate, appropriate and effective for the treatment of the obstetric patient. There will be a natural continuum of skill and ability as the resident becomes more experienced and proficient, with greater attending and a minimum of supervision required at the end of the required rotation. However, it is the resident's responsibility that he/she is always closely supervised by the assigned attending anesthesiologist, who is ultimately responsible for care and well being of the patient.
Specific requirements:
- Preoperative evaluation of the patient, including obtaining pertinent information using available resources such as previous medical records, results of diagnostic tests, and consultations with other services.
- Discuss the planned anesthetic procedure with the assigned attending anesthesiologist.
- Discuss the planned anesthetic procedure and possible risks with the patient and appropriate family members.
- Obtain informed consent for the anesthetic procedure and any related procedures, such as invasive monitoring, regional anesthetic techniques, and any others.
- Provide any necessary education for the treatment of health problems and the promotion of health to the patient and family members.
- Appropriately prepare the operating room for the timely and effective administration of an anesthetic.
- Appropriately care for the patient in the preoperative, intraoperative, and postoperative setting.
2. Medical Knowledge
Residents on the Obstetric Anesthesia rotation must demonstrate knowledge about established and evolving biomedical, clinical, and epidemiological sciences as they relate to the treatment of obstetric patients and the application of this knowledge to patient care.
Specific Requirements:
- Residents are required to demonstrate an investigating and analytical thinking approach to clinical situations.
- Residents must know and apply all basic and clinically supportive sciences such as anatomy, physiology, pathology, pharmacology, biophysics, statistics, and epidemiology as they relate to the treatment of the obstetric patient.
- Residents are expected to read the book chapters included in the syllabus and discuss them with the assigned attending anesthesiologist.
3. Practice-Based Learning and Improvement
Residents on the Obstetric Anesthesia rotation must be able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices.
Specific Requirements:
- Analyze their practice experience and perform improvement activities using a systematic methodology and guidance from the attending anesthesiologist.
- Seek feedback from the attending anesthesiologist as it relates to the delivery of the anesthetic.
- Locate, appraise, and assimilate evidence from scientific studies related to their patients.
- Apply knowledge of study designs and statistical methods to the appraisal of clinical studies and other information on diagnostic and therapeutic effectiveness.
- Use information technology to manage information, access online medical information, and support their own education.
- Facilitate the learning of medical students and other healthcare professionals.
4. Interpersonal and Communication Skills
Residents on the Obstetric Anesthesia rotation are expected to demonstrate strong ethical, interpersonal, and communication skills that result in the excellent care of patients and their family members and effective leadership of the medical staff.
Specific Requirements:
- Create and sustain a therapeutic and ethically sound relationship with patients.
- Use effective listening skills and elicit and provide information using effective nonverbal, explanation, questioning, and writing skills.
- Communicate clearly and respectfully with the attending anesthesiologist and other members of the healthcare team.
5. Professionalism
Residents on the Obstetric Anesthesia rotation must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, sensitivity to a diverse patient population, as well as a consistent commitment to excellence and ongoing professional developments.
Specific Requirements:
- Appropriately communicate with patients and family members about extremely difficult issues, such as end of life issues.
- Demonstrate concern for patients by spending extra time at their bedside.
- Demonstrate a willingness to manage difficult or undesirable anesthetic cases and behave as a member of the medical care team in a busy, overburdened operating room setting.
- Maintain patient confidentiality.
- Demonstrate sensitivity to cultural diversity, ethnicity, religion, sexual orientation, gender, age, social status and disabilities.
6. System-Based Practice
Residents on the Obstetric Anesthesia rotation must demonstrate an awareness of and a responsiveness to the larger context and system of healthcare and the ability to effectively call on system resources to provide care that is of optimal value.
Specific Requirements:
- Practice cost-effective healthcare and resource allocation that does not compromise quality of care.
- Advocate for quality patient care and assist patients in dealing with system complexities.
- Know how types of medical practice and delivery systems differ from one another, including methods of controlling healthcare costs and allocating resources.
Goals and Objectives
General Goals
To provide each anesthesiology resident with a structured educational experience in obstetric anesthesia that will impart the necessary knowledge and skills to provide safe and effective anesthesia care to pregnant patients.
Learning Objectives
The following topics are emphasized in the core curriculum in obstetric anesthesia.
Basic Science Knowledge
- Maternal physiologic adaptations to pregnancy
- Physiology and anatomy of labor pain
- Determinants of fetal/placenta perfusion and oxygenation
- Pharmacology of common neuraxial medications
- local anesthetics
- opioids
- Pharmacology of common uterine stimulants and relaxants
- oxytocin
- ergot alkaloids (methergine)
- Prostaglandin F analogs (hemabate)
- magnesium sulfate
- beta agonists
- nitroglycerin
- amyl nitrite
- Psychology and sociology of the birth experience
Clinical Knowledge
- Airway management in obstetric anesthesia
- importance of preanesthetic airway evaluation
- importance of a plan for managing unexpected difficulty with intubation
- ASA Difficult Airway Algorithm
- importance of immediate access to equipment to implement this plan
- physiologic factors in pregnancy that favor rapid oxygen saturation during apnea
- risk of pulmonary aspiration of gastric contents in pregnant patients
- Hypotension
- relationship between maternal arterial pressure and uterine arterial perfusion
- material supine hypotension syndrome
- evaluation and treatment of maternal hypotension; applying clinical guidelines to individual patients
- Methods of labor analgesia, including:
- psychoprophylaxis (prepared childbirth)
- parenteral narcotics
- inhalation analgesia
- regional anesthesia
- lumbar epidural
- caudal
- intrathecal
- combined spinal-epidural
- continuous spinal
- Anesthesia for cesarean section
- regional anesthesia
- lumbar epidural
- adapting a pre-existing labor epidural for cesarean section
- spinal
- general anesthesia
- nonparticulate antacid
- adequate preoxygenation
- continuous cricoid pressure during rapid sequence induction
- awake intubation, when deemed appropriate by preanesthetic airway evaluation
- Preeclampsia
- etiology, risk factors, diagnostic criteria, natural history
- hemodynamics
- indications for invasive monitoring
- anti-hypertensive therapies
- anti-seizure prophylaxis
- coagulopathies
- qualitative platelet defects
- HELLP syndrome
- eclampsia
- definition
- seizure therapies
- airway management
- management of anesthesia in preeclampsia
- regional
- general
- maternal emergencies
- maternal hemorrhage
- placenta previa
- placenta accrete
- placenta abruption
- amniotic fluid embolus
- venous air embolus
- acute uterine inversion
- trauma
- fetal emergencies
- evaluation of fetal well-being
- biophysical profile
- non-stress test
- contraction stress test
- fetal heart rate monitoring
- baseline rate
- variability: short-term and long-term
- decelerations: early, late and variable
- fetal scalp blood sampling
- fetal distress
- neonatal resuscitation
- obstetrician has the primary responsibility
- Apgar score system
- evolving clinical strategies for interventions in the presence of meconium
- co-existing maternal diseases
- cardiac
- congenital
- acquired valvular heart disease
- respiratory
- asthma
- pneumonia
- endocrine
- diabetes mellitus
- hyperthyroidism
- neurologic
- paraplegia
- multiple sclerosis
- complications of regional anesthesia in OB
- post-dural puncture headache (PDPH)
- differential diagnosis of postpartum headache
- risk factors for PDPH
- natural history of PDPH
- therapeutic options of PDPH
- epidural hematoma
- epidural abscess
- low back pain
- common OB (non-anesthesia) palsies
- maternal morbidity and mortality
- overall rates
- non-anesthesia related
- anesthesia related: regional versus
general anesthesia
- medicolegal issues
- rapport with patients
- informed consent
- emancipated minors
- record keeping
- clinical research: the acquisition of new knowledge and its application to clinical practice
Technical Skills
Gain clinical experience with:
- preanesthetic evaluation of the pregnant patient
- labor analgesia
- epidural
- combined spinal-epidural
- anesthesia for operative OB procedures
- cesarean section
- primary
- repeat
- cerclage
- tubal ligation
- postanesthetic evaluation of the peripartum patient with emphasis on evaluation and treatment of possible complications including post-dural puncture headache
Required Reading
Ostheimer's Manual of Obstetric Anesthesia, David J. Birnbach, 3 rd edition
