The CA-3 Obstetric Anesthesia rotation is meant to provide senior anesthesiology residents with an in-depth obstetric anesthesia experience, including significant independent patient management. During this rotation, the resident will participate in the care of a diverse obstetric population. There will be exposure to routine, low-risk obstetric patients, but the major emphasis of this rotation will be the development of clinical skills needed to independently care for high-risk patients with pregnancy-related disorders or underlying medical problems. Upon completion of the CA-3 Obstetric Anesthesia rotation, the anesthesiology resident will be able to:
- evaluate and develop appropriate anesthetic plans for labor and vaginal delivery as well as operative delivery in high-risk obstetric patients, utilizing in-depth knowledge of obstetric complications and the effects of underlying medical diseases on pregnancy.
- provide anesthetic care for high-risk obstetric patients undergoing vaginal delivery or cesarean delivery with minimal assistance from the anesthesiology attending.
- demonstrate mastery of neuraxial anesthesia techniques, including epidural, combined spinal-epidural, and spinal anesthesia.
- provide effective consultation to obstetricians for high-risk parturients in the antepartum and postpartum period.
- appropriately manage allocation of anesthesia resources on the labor and delivery unit.

The resident will demonstrate skill in the following six competencies:
1. Patient Care
Residents must be able to provide anesthetic care to the parturient that is compassionate, appropriate, and effective for the labor and delivery process as well as obstetric-related surgical procedures. By completion of this rotation, residents are expected to:
A. Mange the anesthetic care of obstetric patients with less serious obstetric complications (such as mild preeclampsia, multiple gestation, placenta previa without severe hemorrhage) independently.
B. Manage the anesthetic care of obstetric patients with serious obstetric complications or underlying medical disorders (such as severe preeclampsia, severe obstetric hemorrhage, cardiac disease) with minimal assistance from anesthesiology faculty.
C. Perform neuraxial anesthesia techniques in patients with normal body habitus in an efficient manner with a very high success rate, i.e.:
1. most completed in 10 min. or less
2. approximately 95% success rate
D. Perform neuraxial anesthesia techniques successfully in the majority of morbidly obese patients.
E. Identify patients that require invasive monitoring (i.e., arterial, CVP, and PA catheter line) and successfully perform those techniques.
F. Use communication and interpersonal skills to function effectively as part of a team with obstetricians, nursing staff, neonatologists, and family practitioners to provide optimal medical, obstetric, and anesthetic care for parturients and their fetuses/neonates.
G. Provide effective anesthetic consultation in the antepartum and peripartum periods to both patients and obstetricians, especially in situations where patients are considered high-risk based on anesthetic, obstetric, or medical factors.
2. Medical Knowledge
Residents must demonstrate knowledge about the pathophysiology of obstetric disorders and underlying medical problems during pregnancy as well as the scientific evidence supporting the effectiveness and safety of specific anesthetic techniques in high-risk parturients. In addition, the resident must demonstrate knowledge about fetal and neonatal evaluation and resuscitation. Residents are expected to demonstrate knowledge of the following:
A. Fetal and Neonatal Physiology
1. Fetal circulation
2. Fetal evaluation
a. for the following tests, define what the test measures, how it is measured, and the clinical implications of positive and negative results
1. nonstress test
2. ocytocin challenge test
3. biophysical profile
4. fetal scalp pH
b. fetal heart rate monitoring
1. define the following terms and explain the mechanisms and clinical implications of each:
a. normal fetal heart rate range
b. fetal tachycardia
c. fetal bradycardia
d. beat-to-beat and long-term variability
e. early decelerations
f. variable decelerations
g. late decelerations
3. Neonatal evaluation and resuscitation
a. explain physiologic adaptations to extrauterine life, including circulatory and respiratory changes
b. resuscitation
1. list maternal and fetal clinical factors that are predictive of a need for neonatal resuscitation
2. describe protocol for neonatal resuscitation
3. explain the resuscitation management of a neonate with meconium staining of amniotic fluid
B. Anesthetic and Obstetric Management of High-Risk Pregnancy For each of the conditions listed, understanding of the following issues should be demonstrated: a. obstetric concerns & standard management, b. anesthetic implications of the condition, c. anesthetic management options for vaginal and cesarean delivery
1. Multiple gestation
2. Preterm labor
3. Abnormal fetal presentations
a. discuss the advantages and disadvantages of using epidural or CSE analgesia to assist with external cephalic version
b. discuss the association between epidural analgesia and abnormal fetal positions (OP,OT)
4. Hypertensive disorders of pregnancy
a. preeclampsia
1. antihypertensive medications
2. management of oliguria
3. indications for invasive monitoring
4. magnesium sulfate effects
b. eclampsia
c. HELLP syndrome
5. Peripartum hemorrhage
a. placenta previa
b. abruptio placenta
1. discuss complications associated with abruptio placenta
c. placenta accreta
1. risk factors
d. uterine rupture
1. risk factors
e. postpartum hemorrhage
1. etiologies
6. Maternal infection
7. Endocrine disease
a. diabetes mellitus
1. criteria for diagnosis and classification during pregnancy
2. effect of pregnancy on diabetes
3. effect of diabetes on fetus/neonate
b. thyroid disease
1. hyperthyroidism
2. hypothyroidism
8. Substance abuse
9. Neurological disorders
a. multiple sclerosis
b. spinal cord injury
1. prevention of autonomic hyperreflexia
c. myasthenia gravis
d. seizure disorders
10. Hematological diseases
a. idiopathic thrombocytopenia purpura
b. von Willebrand’s disease
c. ASRA consensus statement on regional anesthesia and anticoagulants
11. Morbid obesity
12. Musculoskeletal disorders
a. discuss the use of regional anesthesia in the following disorders (technical difficulties, success rates, complications)
1. scoliosis
2. spina bifida cystica
3. prior back surgery including Harrington rod placement
13. Respiratory disease
14. Cardiovascular diseases:
a. congenital heart disease
b. IHSS
c. pulmonary hypertension
d. ischemic heart disease
e. valvular heart disease
1. aortic stenosis
2. aortic insufficiency
3. mitral stenosis
4. mitral insufficiency
5. mitral valve prolapse
f. cardiac dysrhythmias
C. Anesthetic Management of Non-Obstetric Surgery during Pregnancy
1. explain precautions that should be taken in each trimester, including aspiration prophylaxis, prevention of aortocaval compression, and prophylactic tocolysis
2. discuss fetal heart rate monitoring, including when it is indicated and management options when FHT changes occur intraoperatively
3. discuss the safety of anesthetic drugs as it relates to fetal development and pregnancy loss
4. discuss anesthetic options for non-obstetric surgery, including advantages and disadvantages of regional and general anesthesia
D. Pharmacology
1. agents affecting uterine tone
a. anesthetic agents
1. halogenated volatile anesthetics
2. ketamine
2. tocolytic agents
a. magnesium sulfate
b. beta-2 adrenergic agonists
c. Ca channel blockers
d. nitroglycerin
3. uterotonic agents
a. oxytocin
b. methylergonovine
c. 15-methyl prostaglandin F2 alpha
3. Practice-Based Learning and Improvement
Residents must be able to investigate and evaluate their obstetric anesthesia practices, appraise and assimilate scientific evidence, and improve their obstetric anesthesia practices. Residents are expected to:
A. Use information technology to manage information, access on-line medical information, and prepare a presentation on an obstetetric anesthesia topic.
B. Locate, appraise, and assimilate evidence from scientific studies related to obstetric anesthesia care and utilize this information to improve their anesthetic care of parturients.
C. Apply knowledge of study designs and statistical methods to critically analyze obstetric anesthesia clinical studies.
4. Interpersonal and Communication Skills
Residents must be able to demonstrate interpersonal and communication skills that result in effective information exchange with patients, patients’ families, and professional associates. Residents are expected to:
A. Demonstrate the ability to use communication and interpersonal skills to function effectively as part of a team with obstetricians, nursing staff, neonatologists, and family practitioners to provide optimal medical, obstetric, and anesthetic care for parturients and their fetuses and neonates.
B. Demonstrate an ability to communicate with obstetricians the anesthetic concerns for each patient, making certain they are considered when an obstetric plan of care is developed.
C. Provide effective anesthetic consultation to obstetricians for high-risk parturients in the antepartum and peripartum period.
D. Effectively teach obstetric anesthesia principles to junior anesthesia residents, obstetric residents, and nursing staff. This will include preparing a presentation on an obstetric anesthesia topic which will be presented during an OB anesthesia subspecialty conference.
E. Effectively communicate with obstetric patients and their families, including providing thorough discussions of the anesthetic care plan and risks and benefits of anesthetic procedures as well as adequately answering patients’ questions and allaying their anxieties related to anesthesia and surgical procedures.
5. Professionalism
Residents must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. Residents are expected to:
A. Maintain sensitivity and responsiveness to patients’ culture and religion and care for all patients in a nonjudgmental fashion.
B. Demonstrate a commitment to ethical practices, including patient confidentiality, informed consent, and equal treatment of all patients.
C. Demonstrate knowledge of ethical issues specific to obstetrics
1. potential for maternal-fetal conflicts of interest
2. gestational age and fetal weight limits for neonatal survivability
D. Respond in a timely manner to requests by obstetricians and nurses for obstetric anesthesia services.
E. In a sensitive but effective manner, maintain control of the parturient in severe pain while performing anesthesia procedures.
F. Approach in a sensitive and compassionate manner, the woman experiencing a fetal loss.
6. Systems-Based Practice
Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value. Residents are expected to:
A. Perform complete preanesthetic evaluations of parturients admitted to the Labor and Delivery unit, including ordering any necessary laboratory tests, in a timely manner in order to prevent delays in providing labor analgesia or surgical anesthesia.
B. Accurately assess the acuity and anesthetic needs of all patients on the Labor and Delivery unit and allocate obstetric anesthetic resources appropriately based on this assessment when multiple patients are requesting anesthesia services simulataneously.
C. Accurately complete the hospital anesthesia charge sheet and the pharmacy anesthesia charge sheet for all patients who receive obstetric anesthesia care.

Resident Assessment
The final evaluation for the rotation is performed by Dr. Fragneto, Director of Obstetric Anesthesia, after consultation with other faculty members who have worked with the resident during the rotation. The competencies will be assessed by the following methods:
1. Formative evaluation of patient care, medical knowledge, interpersonal and communication skills, and professionalism will be assessed via attending discussions with residents after observation of the resident providing clinical care to patients.
2. A global rating evaluation form will be utilized by Dr. Fragneto at the completion of the rotation to summatively evaluate all six of the general competencies. This evaluation will be based on direct observation and feedback from anesthesiology attendings who have worked with the resident. Feedback from obstetricians and nursing personnel may be included in some cases.
3. Evaluation of the resident’s Obstetric Anesthesia conference presentation and other teaching activities will also be utilized in evaluating communication skills.
4. In some instances, evaluation of practice-based learning and improvement and systems-based practice during this rotation may be included in the resident’s portfolio, utilizing either self-assessment or the Healthcare Matrix.