Obstetrics

1. Definition – Anesthesia for Obstetrics is a one-month rotation for the CA-2 resident which will provide training and learning in the perioperative care of the Obstetric patient.
2. Curriculum – Anesthesia for Obstetrics is a one-month rotation for the CA-2 resident that is spent at University Hospital, which is rated a high risk obstetric center with its Level III nursery.  The resident will be exposed to all patients admitted to the Obstetric ward for delivery, obstetric emergencies, nonobstetric medical evaluation, and prenatal and postpartum obstetric procedures.  Residents will also be involved in evaluation and resuscitation of the newborn.  Significant focus is placed upon perioperative assessment and management of the parturient; technical skill, both airway management and regional techniques; and building solid cognitive foundations in obstetric anesthesia.  Lectures and case discussions by core faculty are provided on a daily basis. Residents will be taking obstetric call while on this rotation. Teaching and supervision is provided by core faculty, including night and weekend call.  A one-month block in the yearly didactic schedule is dedicated to Anesthesia for Obstetrics.
3. Clinical Duties with Learning Pathways:

   1. The resident will perform a comprehensive preanesthesia evaluation on all laboring and preoperative patients.  Special attention and consideration will be paid to coexisting diseases and states, including cardiac disease, asthma, preexisting and gestational diabetes, and obesity.  A plan will be formulated for both nonemergent and emergent care of the parturient, with emphasis placed upon airway evaluation and management.  Documentation of the plan on the preanesthetic evaluation form and in an abbreviated fashion on the daily turnover form is essential to the safe and efficient continuum of care of the obstetric patient, who may be on the labor and delivery floor for many days.  This plan is discussed with and evaluated by the obstetric anesthesia attending.   Residents assuming care of the patient during on-call will familiarize him/herself with the patient and the plan, will reformulate the plan as the patient’s condition changes, and will discuss all changes with the on-call attending.
   2. The resident will have a thorough working knowledge of safe and effective methods of labor analgesia, especially epidural and continuous spinal/epidural anesthesia.  Demonstration of this knowledge is evidence by patient and anesthetic selection, timely and successful placement of epidural catheters, and epidural pump management.  Knowledge of and recognition by follow up of complications related to regional techniques is essential.  All postdural puncture headaches are logged and followed according to the procedure as stated in the “Obstetric Anesthesia Manual”.  All complications are presented by the resident and discussed at the monthly department QA meeting as per Performance Improvement policy.
   3. Special consideration is given to the patient with pregnancy related issues, including preeclampsia/eclampsia and HELLP Syndrome.  Knowledge of pathophysiology; diagnosis, treatment modalities and their side effects; and complications of preclampsia/eclampsia and HELLP Syndrome are understood and demonstrated by presentation of an anesthetic plan to the faculty.  This plan should include considerations common to all patients with these entities as well as a management plan tailored to the changing needs of the individual patient. 
   4. Pharmacologic considerations in the gravid patient include uteroplacental circulation, placental transfer and ion trapping, and teratogenicity. Thorough working knowledge of these considerations is demonstrated by the choice of anesthetic technique and agents used for the laboring patient, the patient undergoing Caesarian section, the obstetric patient undergoing nonobstetric surgery, and the patient undergoing cervical cerclage procedures.  The resident will be able to present these considerations to the patient during the preoperative visit, to the surgical team which may not necessarily be an obstetric team, and to the anesthesia attending.
   5. Fetal well being and its evaluation, although primarily under the domain of the obstetric team, must be understood by the resident in the safe and effective care of the obstetric patient, including fetal blood gas interpretation, fetal heart rate monitoring, and tocodynametry.  The resident, when presented with examples of the above, will be expected to identify and interpret normal and abnormal gases and tracings; present a differential diagnosis for each abnormal presentation; and form a treatment plan.  Further evaluation is based upon the resident’s understanding as evidenced by the timely recognition and treatment of fetal distress during labor analgesia management and during anesthesia for obstetric and nonobstetric surgery.
   6. The resident will in all instances be able to form and implement a treatment plan for anesthetic management of the patient undergoing operative procedures in the obstetric area including elective and nonelective Caesarian delivery, post partum tubal ligation, manual extraction of retained placenta, and cervical cerclage procedures.  Also included in the management plan is the diagnosis and treatment of maternal hemorrhage.  As many of these patients present emergently, the resident will be expected to anticipate said events by knowing at all times what is going on in the unit, and by his/her choice of regional vs. general anesthesia given the urgency of the situation.  Timely delivery of the anesthetic is essential in the obstetric patient, and the resident will facilitate patient turn-over. 
   7. The resident will anticipate the postoperative analgesic needs of the obstetric patient, which requires an understanding of neuraxial narcotics in both intraoperative delivery and postoperative care.  Evaluation is based upon appropriate patient selection, method of delivery, and postoperative follow-up.  Patient controlled analgesia will be understood and utilized by the resident when appropriate.  Neonatal effects of commonly used analgesics in breast fed infants are included.
   8. The resident will have a thorough understanding of neonatal evaluation, including APGAR scoring, neonatal resuscitation, and management of meconium aspiration.  At least one case presentation in the oral board format will be presented to the resident during his/her rotation.  Prioritizing the mother’s needs vs. assisting/directing the resuscitation of the newborn is part of the evaluative process.
   9. An understanding of the special needs and concerns of patients in that community will demonstrate evidence of an awareness of the community served by the hospital in which the resident is rotating.  In the urban setting, these considerations may include lack of prenatal care, teenage pregnancy and its psychosocial implications, and drug addicted parturients.  Evaluation is multifactorial and in addition to anesthesiology faculty includes OB/GYN faculty and residents, nursing and midwife staff, and patients and their families.

4. References – All residents receive a copy of Schneider and Levinson’s Anesthesia for Obstetrics at the start of the CA-2 year.  The resident will prepare for the rotation by reading Chapters 1-4 prior to the start of the rotation; will read Chapters 4-8 prior to completing the rotation; and will read this book in its entirely throughout residency.  Additional material, e.g. journal articles, handouts, etc., are distributed at daily lectures.
5. Objectives - attached
6. Evaluation – All learning objectives will be evaluated as stated in section V.  Each resident will receive at the beginning of the rotation a topic card for discussion by the Director of Obstetric Anesthesia or his designee.  When the resident has prepared and presented this information to the satisfaction of the DOBA or the supervising attending, the card must be signed by the attending.  It is the resident’s responsibility to fulfill these responsibilities as well as to turn in the card to the Resident Education Committee (in the person of Ms. Venino).

Each resident has responsibilities that he must meet in order to complete the rotation successfully.  Similarly, we have the responsibility to ensure that the resident has the environment, the mechanism, and didactic information to meet his learning objectives, as well as the documented evaluation of these objectives.  To that end, the resident will be presenting to you on a topic for discussion or an activity which requires your assistance.  They are as follows: