Obstetric Anesthesiology, MHMC
Case Western Reserve University, MetroHealth Campus
Anesthesiology Resident Education/Training Objectives
Goals and Objectives for CA-1/2 and CA-3 Residents in Obstetrical Anesthesia
- The rotation
Anesthesia residents at the MetroHealth Medical center will be required to participate in a minimum of 2 one-month rotations in L&D; learning Obstetrical Anesthesia. One rotation to be scheduled in the latter half of their CA-1 year, and one month in the CA-II year. In the CA-III year, one or more elective months may be selected.
- Academic Objectives and Goals
For the new resident, it is important to recognize that there is a core of knowledge that must be mastered to become a competent consultant in Obstetrical Anesthesia. The acquisition of this knowledge is vital for not only board certification, but for optimal patient care. The resident will be expected to gain an understanding of the basic principals of perinatal anesthetic delivery in both the normal parturient as well as those with complex medical requirements. They will develop the necessary skills in pre-anesthetic assessment and preparation, intra anesthetic management, and post- operative care including assessment of complications, care and prevention strategies. Additionally, residents in the CA III year will attain additional proficiency in all these areas allowing them to assist in junior resident training, act with more independence in both normal and high risk parturient care, and participate in optional research projects to advance knowledge in this field.
- Knowledge objectives
At the conclusion of the residentís two months of rotation in Obstetrical Anesthesia, the resident will:
a. Have a thorough knowledge of the physiologic changes in pregnancy. b. Understand maternal uptake/distribution, placental transfer, and perinatal effects of volatile anesthetics, barbiturates, ketamine, narcotics, sedatives, tranquilizers, neuromuscular blocking agents, local anesthetics, antihypertensive agents, anticoagulants, Tocolytic, as well as glucose/hypoglycemic agents. c. Understand uterine blood flow itís changes in pregnancy, how regional and general anesthetics effect it, and the effects of vasopressors/antihypertensive agents on it.
d. Understand the physiology of labor, itís stages, how anesthesia effects labor, and how agents used in labor and delivery (like tocolyticís, ergot alkaloids, pitocin, prostaglandinís, etc.) can effect maternal physiology and anesthetic management.
e. Understand and be able to discuss the advantages, disadvantages, and risks of sedation, inhalation, epidural, spinal, and pudendial anesthesia for labor.
f. Understand and be able to discuss the advantages, disadvantages, and risks of local, regional and general anesthesia for the patient undergoing cesarean section.
g. Understand and manage induction, maintenance, and emergence from general anesthesia, the effects of volatile anesthetics on the uterus and fetus, the pros/cons of Nitrous Oxide, and the management of complications such as failed intubation, aspiration, hypotension, hypertension, etc.
h. Understand and be able to discuss the advantages, disadvantages, and risks of anesthesia for the patient undergoing non-obstetric surgery during pregnancy.
i. Understand how agents/ procedures in the induction/augmentation of labor can effect maternal anesthetic care such as amniotomy and the use of oxytocin.
j. Understand the pharmacokinetics / pharmacodynamics of local anesthetics as well as complications/toxicity in the parturient and neonate.
k. Understand the options for post-partum anesthesia care the advantages, disadvantages and risks.
l. Understand and be able to describe the anatomic features and appropriate landmarks necessary to administer a regional anesthetic block including spinal dermatomes and pain pathways.
m. Be able to identify and assess the relative and absolute contraindications to regional anesthesia related to coagulopathy, neurologic disease, hypovolemia, drug allergy, fever/sepsis, backache, scoliosis, etc.
n. Understand, recognize, and manage patients with medical conditions in pregnancy such as: 1) pregnancy inducted hypertension
2) cardiac disease (congenital/ischemic/valvular/cardiomyopathy)
3) respiratory disease (restrictive/obstructive)
4) bleeding disorders in pregnancy ( placenta previa, abruption, accreta, etc.)
6) morbid obesity
7) difficult airways 8) the causes of cardio- respiratory arrest
9) misc. disorders ( thyroid, NM disorders, MH, coagulopathies)
10) the patient with PDPH
o. Describe/manage complications of regional anesthesia in pregnancy hemodynamic, backache, bladder dysfunction, neurologic sequela, infection, headache, etc.
p. Understand and discuss obstetric and neonatal indications for cesarean section both elective and emergent and be able to discuss the risk/benefits of the various options for anesthetic management.
q. Be able to discuss the obstetrical considerations/management of labor complications such as breech delivery, cord prolapse, transverse lie, multiple gestation, brow presentation, premature rupture of membranes, and premature delivery.
r. Understand the management of maternal hemorrhage and the risks associated with such conditions as: previa, abruption, accreta, uterine rupture, uterine atony, retained placenta, uterine inversion, DIC.
s. Understand the basic anatomy and physiology of the feto-placental unit, ante-partum fetal monitoring and assessment including non stress testing, oxytocin stress testing, biophysical profile, fetal lung maturity testing, fetal heart rate monitoring, and fetal pH monitoring.
t. Understand, be able to discuss peripartum fetal asphyxia diagnosis/management of neonatal disorders such as meconium aspiration, diaphragmatic hernia, T-E fistula, sepsis, RDS of the newborn.
- Skill Objectives
a. To be able to safely and thoroughly prepare an operating room to be ready to administer an anesthetic for vaginal/cesarean delivery.
b. To be proficient in the placement and management of regional anesthesia (both spinal and epidural anesthetics) in all clinical setting for labor, cesarean delivery, D&C;, postpartum tubal ligation, cerclage, etc. The goal is to do a minimum of 50 regional anesthetics per month.
c. To be able to select appropriate monitoring for the various clinical settings that occur in the parturient.
d. To be able to safely administer general anesthesia to the parturient in both the non- emergent and emergent setting for both vaginal and cesarean delivery.
e. To be able to pre-operatively evaluate and design a safe anesthetic plan for the anesthetic management of: 1) The healthy parturient for vaginal delivery with or w/o the use of forceps.
2) The healthy parturient presenting for elective cesarean section
3) The healthy parturient presenting for emergency cesarean section.
4) The parturient with Preeclampsia/Eclampsia for either vaginal/cesarean section
5) The parturient with antepartum/intrapartum/postpartum hemorrhage
f. To be familiar with the diagnosis and management of the fetal/neonatal distress.
g. Learn to interact/communicate effectively with all allied personnel in the obstetric care team, to lead in the pre-anesthetic evaluation, labor, intra-operative and post-operative care as well as maternal/fetal resuscitation.
h. Learn to function as a consultant to patients, families, colleagues in anesthesia, obstetrics and other specialties.
- Literature Conference Obligations
a. Attendance at Tuesday morning 7 AM grand rounds.
b. Attendance at Wednesday afternoon 1 PM resident lecture.
c. Attendance at Friday afternoon 1 PM resident lecture.
d. The resident is to read all 16 chapters of the Obstetrical Anesthesia handbook that is supplied by the secretarial staff. They are to be able to answer the questions provided in each chapter of the manual. They are then to present each chapter to the attending staff to demonstrate their command of the information. The attending will then sign off on each chapter the resident presents. At the end of each rotation 8 chapters are to be completed and the resident is to give the signature sheet to the secretary at the end of the month.
e. Shnider, S MD and Levinson, G. Anesthesia for Obstetrics
f. Ostheimer, Gerald, MD Manual of Obstetric Anesthesia
g. Gambling DR, Douglas J, Obstetric Anesthesia and Uncommon Disorders