OBSTETRIC ANESTHESIA: OUTLINE OF CURRICULUM GOALS FOR ANESTHESIA RESIDENTS
COMPLETING CLINICAL ANESTHESIA YEAR 3
General Issues
- Ability to function as part of a team with obstetricians, nursing staff,
nurse midwives, neonatologists and pediatricians to provide optimal medical,
obstetric, and anesthetic care for parturients and their fetuses/neonates.
- Familiarity with the ASA guidelines pertaining to obstetric anesthesia.
1. MATERNAL PHYSIOLOGY
Knowledge
1. Maternal physiology: time course and changes during gestation.
a. Cardiovascular adaptations to pregnancy.
b. Pulmonary, respiratory, and airway changes.
c. Gastrointestinal, hematologic, and renal changes.
2. MAC and local anesthetic adjustments during pregnancy.
3. Approach to CPR in a parturient, awareness of need for delivery of baby.
2. FETAL AND PLACENTAL PHYSIOLOGY
Knowledge
1. Placental development, structure and inability to autoregulate placental
flow.
2. Placental gas exchange, nutrient transport, drug tranfer.
3. Antenatal fetal evaluation (growth, fluid, positions, biophysical profile).
4. Fetal circulation.
5. Fetal and neonatal effects of maternally administered anesthetic drugs.
6. Fetal adaptations to hypoxia.
7. Fetal heart rate patterns during labor and their response to hypoxia or
asphyxia.
Skills
1. Ability to describe impact on fetus of drop in maternal cardiac output.
2. Ability to interpret obstetric information about fetus.
3. Ability to interpret fetal heart rate patterns during labor.
3. NEONATAL PHYSIOLOGY
Knowledge
1. Intrapartum fetal resuscitation.
2. Neonatal physiologic adaptations to extrauterine life.
3. Resuscitation of the newborn - NALS protocol.
Skills
1. Can predict the likelihood of need for resuscitation.
2. Recognizes neonate needing resuscitation.
3. Can initiate resuscitation of a neonate.
4. PATTERNS AND OBSTETRIC MANAGEMENT OF LABOR
Knowledge
1. Physiology of labor and the smooth muscle of the uterus.
2. Define the stages of labor and typical duration.
3. Effect of uterine contractions on placental exchange and fetal oxygenation.
4. Indications for analgesia during labor.
5. Effect of analgesia on labor and delivery.
6. Effect on labor of maternal hydration, position, hyperventilation, hypotension.
Skills
1. Recognize and treat uterine hypertonus or hyperstimulation.
5. OBSTETRIC INDICATIONS FOR/MANAGEMENT OF URGENT ABDOMINAL DELIVERIES
Knowledge
1. Obstetric indications for abdominal delivery and classification according
to urgency.
2. Inherent maternal anesthetic risk of urgent or emergent delivery.
3. Surgical and anesthetic management of bleeding during delivery, including
drug therapy, surgical maneuvers, transfusion therapy.
Skills
1. Facility in institution of rapid sequence general anesthesia.
2. Ability to manage a difficult airway (may include facility with fiberoptic,
awake, retrograde wire intubation or cricothyrotomy etc.)
3. Facility and safe practice in instituting urgent regional anesthesia.
6. LOCAL ANESTHETICS FOR OBSTETRICS
Knowledge
1. General principles of local anesthetic pharmacology.
2. Treatment of systemic local anesthetic toxicity, including maternal seizure
or cardiotoxicity.
3. Response to total or near total spinal.
4. Effect of local anesthetics on the uterus and fetus.
5. Effect of vasoconstrictors and other local anesthetics additives on the
uterus and fetus.
6. Placental transfer and fetal uptake (potential for fetal ion trapping).
7. Fetal and newborn local anesthetic toxicity.
8. Potential for maternal local anesthetic neurotoxicity.
Skills
1. Ability to make logical choice of local anesthetic and dosage for labor
analgesia or cesarean delivery.
2. Ability to describe and perform steps in resuscitation from toxicity.
7. NEURAXIAL OPIOIDS FOR OBSTETRICS
Knowledge
1. General principles of neuraxial opioid pharmacology.
2. Treatment of opioid side effects and toxicity, including maternal respiratory
arrest.
3. Effect of opioids on the uterus and fetus.
4. Interaction between neuraxial opioids and local anesthetics.
Skills
1. Ability to make logical choice of opioid and dosage for labor analgesia,
cesarean delivery or post-cesarean pain management.
2. Ability to describe and perform steps in resuscitation from respiratory
arrest.
8. REGIONAL ANESTHESIA FOR OBSTETRICS
Knowledge
1. Pain pathways involved in labor and delivery.
2. Options available for maternal comfort.
3. Contraindications to regional anesthesia.
4. Management of the alterations in the cardiovascular and respiratory systems
caused by neuraxial analgesia or anesthesia.
5. Approach to inadequate regional anesthesia during labor or operative delivery.
6. Convert labor analgesia to anesthesia for operative delivery.
7. Complications of regional anesthesia and their treatment: postdural puncture
headache, maternal backache, maternal nerve palsy, epidural abscess or hematoma.
Skills
1. Demonstrates aseptic technique for major regional blocks.
2. Performs safe and effective subarachnoid and epidural blockade for labor
analgesia, operative delivery and postpartum tubal ligation.
3. Demonstrates adequate documentation of regional techniques and subsequent
maternal and fetal monitoring.
4. Facility performing epidural blood patch.
9. GENERAL ANESTHETICS FOR OBSTETRICS
Knowledge
1. Indications for general endotracheal (GETA) anesthesia.
2. Ventilatory requirements of parturients.
3. Medication choices for induction and maintenance and the appropriate doses
for cesarean delivery.
4. Impact on the fetus of the induction to delivery and uterine incision to
delivery intervals.
Skills
1. Ability to develop a plan for general endotracheal anesthesia based on
the physiologic and physical changes of pregnancy.
2. Ability to recognize and outline management of a difficult airway based
on physical examination of neck, oropharynx and body habitus.
3. Ability to outline a failed intubation plan following the ASA algorithm.
4. Ability to recognize pulmonary aspiration of gastric contents and outline
a plan for the PACU and postoperative care of a patient who has aspirated.
10. OBSTETRICAL COMPLICATIONS AND THEIR MANAGEMENT
Knowledge
1. Understand management of maternal ante- or postpartum hemorrhage (uterine
rupture, abruption or atony, placenta previa or accreta, retained placenta).
2. Understand treatment for maternal embolic events - amniotic fluid, air
or thrombus.
11. MEDICAL DISEASES DURING PREGNANCY & THEIR PERI-OPERATIVE MANAGEMENT
For each of the following disease categories:
1. General understanding of how the disease impacts on pregnancy.
2. General understanding of how pregnancy impacts on the disease.
3. General understanding of the obstetric implications and management of the
disease.
4. Ability to communicate the anesthetic implications of the disease to non-anesthesiologist
colleagues attending the patient.
5. Assess the severity of disease and evaluate the need for patient transfer
to a high risk facility.
6. Describe the anesthetic management of the patient for vaginal or cesarean
delivery.
A. Hypertensive Disorders of Pregnancy
Knowledge
1. Classification of hypertensive disorders during pregnancy.
2. Epidemiology of preeclampsia - risk factors
3. Pathophysiology of preeclampsia as a multisystem disease.
4. Medical/obstetric management of preeclampsia.
a. term vs. preterm fetus.
b. mild vs. severe disease.
c. assessment of fetal well being.
d. seizure prophylaxis; magnesium sulfate effects.
e. antihypertensive therapy
f. management of oliguria.
g. indications for invasive monitoring.
5. Anesthetic selection for and management of the preeclamptic parturient.
a. labor and vaginal delivery.
b. abdominal delivery - non-urgent.
c. abdominal delivery - urgent.
Skills
1. Ability to diagnose the parturient with preeclampsia.
2. Ability to identify the patient requiring invasive monitoring.
3. Ability to effectively treat the patient with an eclamptic seizure.
B. Morbid Obesity
Skills
1. Ability to perform successful regional anesthesia techniques in morbidly
obese parturients.
C. Respiratory Disease Knowledge
1. Asthma
2. ARDS
D. Cardiac Disease
Knowledge
1. Understand when invasive monitors are needed for delivery and postpartum
care.
a. Congenital Heart Disease.
1. left to right shunt.
2. right to left shunts (Tetrology of Fallot)
3. pulmonary hypertension (Eisenmenger=s Syndrome).
4. coarctation of aorta.
b. IHSS.
c. Ischemic Heart Disease.
d. Valvular Heart Disease.
1. aortic stenosis.
2. aortic insufficiency.
3. mitral stenosis.
4. mitral regurgitation.
e. Peripartum cardiomyopathy.
E. Endocrine Disease.
Knowledge
1. Diabetes mellitus.
2. Thyroid disease.
a. hyperthyroidism.
b. hypothyroidism.
Skills
1. Ability to manage glucose control in the parturient during cesarean or
vaginal delivery.
F. Hematologic and Coagulation Disorders.
Knowledge
1. Anemias.
2. Coagulation disorders.
G. Neurologic Disease.
Knowledge
1. Multiple sclerosis.
2. Spinal cord injury.
3. Myasthenia gravis.
4. Seizure disorders.
5. Subarachnoid hemorrhage or vascular malformations.
H. Substance Abuse and HIV Infection
Knowledge
1. Substance abuse.
a. ethanol abuse.
b. opioid abuse and barbiturate use.
c. cocaine abuse.
2. HIV infection.
I. Miscellaneous Disorders.
1. Renal Disease.
2. Liver Disease.
3. Musculoskeletal Disorders.
4. Scoliosis.
5. Rheumatoid arthritis.
6. Spina bifida cystica.
7. Autoimmune Disorders.
8. Prior back surgery including Harrington rod placement.
12. ANESTHETIC MANAGEMENT OF NON-OBSTETRIC SURGERY DURING PREGNANCY
Knowledge
1. Considerations for elective surgery during pregnancy.
2. Understand when and which medicines may be teratogens.
3. Considerations for trauma or emergency surgery during pregnancy.
4. Understand when fetal monitoring is needed during maternal surgery.
5. Physiology of pregnancy as it might impact cardiovascular, respiratory
and transfusion decisions during surgery.
Skills
1. Ability to discuss risks of elective surgery with patients and colleagues.
13. ETHICAL ISSUES
Knowledge
1. Awareness of potential for maternal-fetal conflicts of interest (e.g.
general anesthesia for stat cesarean delivery in face of perceived fetal jeopardy)
2. Respect for all moral and religious points of view (e.g. Jehovah Witness
patient)
3. Awareness of fetal development and current limits of viability.
Skills
1. Recognizes own ethical attitudes versus patient's moral concerns and is
willing to arrange for non-prejudicial transfer of care, if necessary.
2. Recognizes need for timely consultation on difficult moral and legal issues.
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