Download Advanced Obstetrical Goals and Objectives

INDIANA UNIVERSITY DEPARTMENT OF ANESTHESIOLOGY
ADVANCED CA2/CA3--Obstetrical Anesthesia
Goals and Objectives
GOALS and OBJECTIVES:
This advanced rotation is meant to provide you with the competencies required to meet the
expectation of a Board Certified (Consultant) Anesthesiologist.
The goal of the Advanced Obstetrical Anesthesia Rotation at the Indiana University School of
Medicine is to train physicians to be competent and compassionate practitioners of Obstetrical
Anesthesia. We expect the residents to be able to more readily evaluate and develop treatment
plans regarding patient care issues then during their previous rotations in the Core Obstetrical
Anesthesia rotation. This rotation like the core rotation in Obstetrical Anesthesia is designed to
develop the appropriate attitudes, knowledge, and skills required to care for these patients.
Trainees will greatly expand their knowledge, skills, and judgment so that they can recognize
and manage pre-operative, intra-operative and post-operative complications associated with
Obstetrical Anesthesia.
Basic Obstetrical Anesthesia Resident Duties:
1. Preoperatively evaluate and develop a plan for the administration of a safe obstetrical
anesthetic
2. Intraoperatively maintain safe anesthetic care for the mother and fetus with specific
consideration of how the physiologic changes of pregnancy affect the delivery of
anesthesia
3. Preoperatively evaluate and develop a safe analgesic plan for the management of labor
and vaginal delivery
4. Understand how the physiologic changes of pregnancy and the stresses of labor and
delivery affect the delivery of labor analgesia
5. Post-operatively/post delivery understand potential complications to both the mother and
fetus associated with the delivery of obstetrical anesthesia/analgesia
6. Attendance at didactic conferences
7. Taking night call on a rotating schedule
8. Attending to Obstetrical Anesthesia consults in a timely fashion
9. Develop a personal program of self-study and professional growth
10. Complete medical records promptly
11. Document all duty hours
12. Document all procedures
13. Monitor self for fatigue
14. Dress appropriately
15. Act in a professional and ethical manner
16. Complete the appropriate evaluation instruments used by the department, including QA
forms
Educational Strategy:
The Obstetrical Anesthesia Rotation is a one-month block. During the Obstetrical Anesthesia
Rotation residents will be supervised by various members of the anesthesia teaching faculty but
their educational experience will be supervised by the Director of Obstetrical Anesthesia, Dr.
Adam Lemmon. In his absence, Dr. Samantha Yeap will fulfill these responsibilities. During
the rotation in obstetrical anesthesia, residents are expected to participate in journal clubs, and
morbidity and mortality conferences (QA). Additionally, a packet of materials has been
compiled by the Director of Obstetrical Anesthesia and is provided as a means of enhancing their
educational experience.
When rotating at Eskenazi Hospital please contact Dr. Amy Dorwart if any questions arise
regarding this rotation.
During the rotation in chronic pain, residents are expected to participate in journal club, and
morbidity and mortality conferences (QA).
Core Competencies:
The six core competencies are utilized as a template to evaluate residents during all Anesthesia
rotations. Residents will realize that of the vocabulary used to define these competencies are
similar to those used for other rotations. The Goals and Objectives that follow have been
specifically modified to represent a higher degree competency then during your Core Obstetrical
Anesthesia training. We ask you as the learner to consider how each of the subcategories within
these six competencies might relate to cognitive, motor and affective characteristics of your
education and your professional behavior. If while reading this document you discover an area
that requires update or improvement please bring these issues to the attention of either the
Course Director or the Program Director. We seek changes that will improve your educational
experience.
EDUCATIONAL OBJECTIVES
Medical Knowledge:
After completing this rotation, residents will have gained knowledge and practical experience in
the care of cardiac patients by understanding the complexities associated with the care of patients
with cardiac disease. Additionally, the ADVANCED Obstetrical Anesthesia rotation is meant to
sharpen the residents knowledge base to the degree expected of a consultant in obstetrical
anesthesia. We believe that the below ABA content outline provides the benchmark upon which
the above expectations are founded.
Obstetric Anesthesia
a. Maternal Physiology
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1) Effects of Pregnancy on Uptake and Distribution
2) Respiratory (Anatomy, Lung Volumes and Capacities, Oxygen Consumption,
Ventilation, Blood Gases, Acid Base)
3) Cardiovascular (Aorto-Caval Compression, Regulation of Uterine Blood Flow)
4) Renal
5) Liver (Albumin/Globulin Ratio, Protein Binding of Drugs)
6) Gastrointestinal (Gastric Acid, Motility, Anatomic Position, Gastroesophageal
Sphincter Function)
7) Hematology (Blood Volume, Plasma Proteins, Coagulation)
8) Placenta
a) Placental Exchange - O2, CO2
b) Placental Blood Flow
c) Barrier Function
b. Maternal-Fetal Considerations
1) Pharmacology
a) Anesthetic Drugs and Adjuvants
b) Oxytocic Drugs (Indications, Adverse Effects)
c) Tocolytic Drugs (Indications, Adverse Effects)
d) Antiseizure Drugs; Interactions (Magnesium Sulfate)
e) Mechanisms of Placental Transfer, Placental Transfer of Specific Drugs
f) Fetal Disposition of Drugs
g) Drug Effects on Newborn
2) Amniotic Fluid (Amniocentesis, Oligohydramnios, Polyhydramnios)
3) Antepartum Fetal Assessment and Therapy (Ultrasonography, FHR Monitoring,
Nonstress Test, Stress Test, Biophysical Profile)
4) Anesthetic Techniques and Risks (Elective vs. Emergency, General vs. Regional)
a) Systemic Medications: Opioids, Sedatives, Inhalational Agents
b) Regional Techniques
(1) Epidural, Caudal, Spinal, Combined Spinal/Epidural
(2) Paracervical Block, Lumbar Sympathetic Block, Pudendal Block
c) Complications (Aspiration, Nerve Palsies)
5) Physiology of Labor (Metabolism, Respiration, Cardiovascular, Thermoregulation)
6) Influence of Anesthetic Technique on Labor
7) Cesarean Delivery: Indications, Urgent/Emergent, Anesthetic Techniques and
Complications, Difficult Airway, Aspiration Prophylaxis
c. Pathophysiology of Complicated Pregnancy
1) Problems During Pregnancy and Delivery
a) Anesthesia for Cerclage or Non-Obstetric Surgery
b) Ectopic Pregnancy
c) Spontaneous Abortion
d) Gestational Trophoblastic Disease (Hydatid Mole)
e) Autoimmune Disorders (Lupus, Antiphospholipid Syndrome)
f) Endocrine (Thyroid, Diabetes, Pheochromocytoma)
g) Heart Disease (Valvular Disorders, Pulmonary Hypertension, Congenital Heart
Disease, Arrhythmias, Cardiomyopathy)
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h) Hematologic (Sickle Cell Anemia, Idiopathic Thrombocytopenic Purpura, Von
Willebrand Disease, Disseminated Intravascular Coagulation (DIC),
Anticoagulant Therapy, Rh and ABO Incompatibility)
i) Hypertension (Chronic, Pregnancy-Induced)
j) Neurologic (Seizures, Myasthenia, Spinal Cord Injury, Multiple Sclerosis,
Subarachnoid Hemorrhage)
k) Respiratory (Asthma, Respiratory Failure)
l) Renal
m) Human Immunodeficiency Virus Infection
2) Problems of Term and Delivery
a) Intrapartum Fetal Assessment (Fetal Heart Rate Monitoring, Fetal Scalp Blood
Gases, Fetal Pulse Oximetry)
b) Preeclampsia and Eclampsia
c) Supine Hypotensive Syndrome
d) Aspiration of Gastric Contents
e) Embolic Disorders (Amniotic Fluid Embolism, Pulmonary Thromboembolism)
f) Antepartum Hemorrhage (Placenta Previa, Abruptio Placenta, Uterine Rupture)
g) Postpartum Hemorrhage (Uterine Atony, Placenta Accreta)
h) Cord Prolapse
i) Retained Placenta
j) Dystocia, Malposition, and Malpresentation (Breech, Transverse Lie)
k) Maternal Cardiopulmonary Resuscitation
l) Fever and Infection
m) Preterm Labor
n) Vaginal Birth After Cesarean Section (VBAC)
o) Multiple Gestation
3) Resuscitation of Newborn
a) Apgar Scoring
b) Umbilical Cord Blood Gas Measurements
c) Techniques and Pharmacology of Resuscitation
d) Intrauterine Surgery (Maternal and Fetal Considerations, Intrauterine Fetal
Resuscitation)
Patient Care:
Using the above medical knowledge the resident is expected to:
1. Evaluate obstetrical patients and develop a treatment plan
a. Resident is expected to distinguish between underlying changes associated
with pregnancy
b. Resident is expected to understand the relationship between mother and fetus
c. Resident is expected to understand the impact of co-existing disease to both
mother and fetus
2. Plan a comprehensive approach to obstetrical anesthesia problems
3. Plan a comprehensive plan for either preoperative or intrapartum assessment and
management of the pregnant patient
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4. Demonstrate the ability to function as a obstetrical anesthesia consultant and
specialist
5. Analyze the administration/complications/benefits of the various pharmacologic
agents used in obstetrical anesthesia
6. Prepare patients for surgery and invasive obstetrical anesthesia procedures
7. Participate in and perform invasive interventional procedures associated with the safe
conduct of an obstetrical anesthesia/analgesic under attending supervision.
8. Skillfully perform various techniques, including, but not limited to:
a. Spinal anesthesia for cesarean section
b. Placement of epidurals for labor, delivery and cesarean section
c. Combined spinal-epidural for labor, delivery and cesarean section
d. Placement of central venous lines
e. Placement of arterial lines
9. Become competent in managing regional anesthesia techniques for cesarean sections,
labor and other obstetrical procedures, as well as becoming competent in managing
complications of obstetrical anesthesia
10. Demonstrate the ability to function as a consultant in obstetrical anesthesia
Interpersonal and Communication Skills:
After completing this rotation, residents will have gained experience and competence in:
1. Obtaining an accurate, useful patient history appropriate for obstetrical anesthesia
2. Completing an informative, legible medical record
3. Communicating skillfully with patients and family members
4. Communicating information about anesthetic procedures with other colleagues
including referring physicians, nurses, and workers on ancillary services
5. Effective counseling of patients and families regarding methods of obstetrical
anesthesia/analgesia, alternatives, and risks and benefits of treatment options
6. Obtaining informed consent for obstetrical anesthesia procedures
7. Answering questions from the patient and or family members regarding obstetrical
anesthesia/analgesia issues in a fashion that is readily understood
Professionalism:
After completing this rotation, residents will have gained experience and competence in:
1. Acting in a professional manner while providing patient care
2. Demonstrating reliability and dependability
3. Exemplifying compassionate and appropriate patient care
4. Acquiring teaching skills essential for creating a positive learning environment,
including involvement in the education of medical students
5. Showing respect for patients
6. Providing for the emotional needs of patients
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Systems-Based Practice
After completing this rotation, residents will have gained experience and competence in:
1. Understanding their role as a patient care advocate
2. Becoming familiar with the costs associated with the delivery of anesthesia care
3. Incorporating the concepts of cost-benefit analysis when considering therapeutic
options
4. Interpreting the constraints associated with management of the operating room and be
able to integrate this understanding into best patient care practices
5. Emphasizing safety for the patient as well as operating room personal
6. Obtaining a better understanding of the tools that are being utilized to assess best
practices in anesthesia by organizations such as Magnet and Leapfrog
7. Working towards developing team building skills
Practice Based Learning and Improvement:
After completing this rotation, residents will have gained experience and competence in:
1. Self-directed learning
2. Becoming more efficient at locating medical information associated with acute pain
3. Reviewing the medical literature related to the field of acute pain and integrating this
information with the care of the patient
4. Learning to better utilize information technology to access on-line medical
information pertaining to innovative diagnostic and therapeutic modalities in the area
of acute pain
5. Transferring knowledge about acute pain to other members of the healthcare team
(medical students, ancillary care personal and nursing staff)
Trainee Evaluations:
The Anesthesia Clinical Competency Committee (CCC) meets every other month to evaluate the
progress of the trainees. Specifically addressed are the six basic competencies and the obstetrical
anesthesia specific competencies outlined above. The instruments used to assess their progress
include an evaluation form which utilizes a scaled five point Likert scoring system which
assesses each of the six competencies. In house testing is also performed twice yearly to insure
that the trainees are acquiring the knowledge associated with the provision of a safe anesthetic.
Residents are expected to take the in-training examination administered by the American Society
of Anesthesiologists/American Board of Anesthesiology (ASA/ABA).
On a more informal (and potentially more important) level, members of the teaching faculty
evaluate our trainees daily and provide them real-time feedback concerning their performance in
the delivery of anesthesia services. Informal discussions with the obstetrical anesthesia residents
address any deficiencies in patient care or knowledge base. Additionally, we try to know our
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trainees personally to better understand and/or address underlying stressors or personal issues
that may interfere with learning and performance.
Every six months, the American Board of Anesthesiology requires that the Clinical Competency
Committee submit a Resident Training and Evaluation Report. In addition to the basic
competencies, we submit our evaluation of a trainee’s progress in the following areas:
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Demonstrates ethical/moral behavior
Is reliable, conscientious, responsible and honest
Learns from experience; knows limits
Reacts to stressful situations appropriately
Has no documented abuse of alcohol or illegal use of drugs during this report
period
Has no cognitive, physical, sensory or motor impairment that precludes individual
responsibility for any aspect of anesthetic management
Demonstrates respect for the dignity of patients and colleagues
Has no restriction, condition, limitation or revocation of license to practice
medicine
Collects and uses clinical data
Recognizes the psychological factors modifying pain experience
Communicates/works effectively with patients/colleagues
Demonstrates appropriate concern for patients
Demonstrates commitment to life long learning
Adapts and is flexible
Is careful and thorough
Generates complete, legible, and accurate medical record
Possesses business skills for effective practice management
Uses information technology to optimize patient care
Is an advocate for quality care
Recognizes gaps in knowledge and expertise
Demonstrates continuous practice improvement
Uses appropriate technical skills in diagnostic and therapeutic procedures
Faculty Evaluations:
The trainees evaluate all members of the teaching anesthesia faculty twice yearly. This is
accomplished formally by a scaled questionnaire that addresses faculty knowledge, technical
skills, professionalism, and teaching ability. Comments regarding faculty are freely solicited.
Each faculty member is counseled by the Program Director in consultation with the Chair when
deficiencies in teaching or performance are detected. The Chair of the Department of Anesthesia
formally evaluates each faculty member yearly.
Suggested Readings:
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Suggested reading assignments to expand knowledge and patient care for this rotation include
but are not limited to the most recent editions of the following textbooks:
Obstetrical Anesthesia 3rd ed. - Chestnut
Anesthesia for Obstetrics 4th ed. - Shnider and Levinson
Practical Obstetric Anesthesia - Dewan and Hood
Handbook of Obstetric Anesthesia - Palmer, D’angelo, Paesh
Anesthetic and Obstetric Management of High Risk Pregnancy - Datta
Evidence Based Obstetric Anesthesia - Halpern
Obstetric Anesthesia Handbook 3rd ed - Datta
Clinical Anatomy of the Lumbar Spine and Sacrum – Bogduk
Clinical Anesthesia 5th ed. - Barash, Cullen, Stoelting: Chap 26 - Epidural and Spinal
Anesthesia; Chap 42 - Obstetrical Anesthesia
Anesthesia and Co-Existing Disease - Stoelting & Dierdorf 4th ed.: Chap. 31 - Diseases
Associated with Pregnancy
For guidance regarding regional analgesia for obstetrical surgery/analgesia the most recent
editions of the following textbooks are recommended:
Atlas of Regional Anesthesia – Brown
Peripheral Nerve Blocks: Principles and Practice--Admir Hadzic, Jerry Vloka
Neural Blockade – Cousins
Regional Block – Moore
Review articles on obstetrical anesthesia topics in the following peer reviewed journals provide
useful reading:
Anesthesiology
Anesthesia and Analgesia
British Journal of Anesthesia
Regional Anesthesia and Pain Medicine
International Journal of Obstetrical Anesthesia
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