The CA-1/CA-2 Obstetric Anesthesia rotation is meant to provide all residents by the end of the CA-2 year with an initial exposure and understanding of obstetric anesthesia. During this rotation, which will include at least 2 months experience in obstetric anesthesia during the CA-1 and CA-2 years, the resident will participate in the care of a diverse obstetric population. Exposure to both routine, low-risk obstetric patients as well as high-risk patients with pregnancy-related disorders or underlying medical problems will occur. Upon completion of the CA-1/CA-2 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 low-risk obstetric patients, utilizing knowledge of the anesthetic implications of the physiologic changes of pregnancy.
- provide anesthetic care for low-risk obstetric patients undergoing routine vaginal delivery or cesarean delivery with minimal assistance from the anesthesiology attending.
- utilize a basic knowledge of common obstetric complications and the effects of underlying medical diseases on pregnancy to evaluate and develop anesthetic plans, with some assistance from the anesthesiology attending, for high-risk obstetric patients.
- demonstrate proficiency in neuraxial anesthesia techniques, including epidural, combined spinal-epidural, and spinal anesthesia.
- manage the common complications associated with neuraxial anesthesia techniques.
- communicate effectively with health care professionals and patients in order to provide optimal anesthetic care to parturients and their fetuses/neonates
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. Manage the anesthetic care of a routine obstetric patient for uncomplicated vaginal or cesarean delivery as well as other obstetric procedures such as tubal ligation, cervical cerclage, and D&C with minimal assistance.
B. Manage the anesthetic care of obstetric patients with less serious obstetric complications (such as mild preeclampsia, multiple gestation, placenta previa without serious hemorrhage) with moderate assistance from anesthesiology faculty.
C. 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 significant assistance from anesthesiology faculty.
D. Perform neuraxial anesthesia techniques on patients with normal body habitus with a success rate of approximately 80%.
E. Perform the following case numbers by completion of the CA-1/CA-2 Obstetric Anesthesia rotation: 40 epidural/CSE techniques for labor analgesia, 20 cesarean deliveries.
F. Effectively discuss obstetric anesthesia options to parturients presenting to the Labor and Delivery suite in a nonjudgmental manner.
G. Use appropriate communication to allay the anxiety of parturients undergoing anesthesia procedures and surgery under regional anesthesia.
2. Medical Knowledge
Residents must demonstrate knowledge about the effectiveness and complications of obstetric anesthesia procedures and the scientific evidence supporting the use of these techniques. In addition, the resident must demonstrate knowledge about the physiologic state of pregnancy and its anesthetic implications, the labor and delivery process, common obstetric complications as well as the pharmacology of commonly used obstetric anesthesia drugs. Residents are expected to demonstrate knowledge of the following:
A. Maternal physiologic changes of pregnancy and their anesthetic implications
1.    1. Cardiovascular system 
2. Respiratory system 
3. Gastrointestinal system 
4. Hematologic system 
5. Renal system 
6. Endocrine and metabolic systems 
7. CNS changes
B. Placental physiology
1. Understand the physiologic and pathophysiologic processes that alter placental blood flow; explain the mechanisms and clinical significance of these changes in placental blood flow
C. Physiology of labor and delivery process
1. Describe first (active and latent phases), second and third stages of labor, noting events that define each stage, normal duration of each stage, and differences in these stages between nulliparous and multiparous women
1.    2. Explain the effects of epidural analgesia on the duration of the first & second stage of labor and the incidence of C/S and instrumental vaginal deliveries
D. Regional anesthesia for obstetrics
1. Describe the anatomy of the epidural space
1.    2. Describe the neurological pathways that transmit pain information during the first and second stages of labor
1.    3. List all regional anesthesia techniques that can produce effective analgesia during the first stage of labor
1.    4. List all regional anesthesia techniques that can produce effective analgesia during the second stage of labor
1.    5. List all regional anesthesia techniques that can produce effective anesthesia for cesarean delivery
1.    6. Explain the absolute and relative contraindications to regional anesthesia in obstetric patients
1.    7. Describe the hemodynamic effects of epidural and spinal anesthesia in obstetric patients 
a. discuss treatment options for epidural or spinal-induced hypotension 

8. Discuss the advantages and disadvantages of epidural, combined spinal-epidural, and spinal techniques
9. Discuss approaches to managing inadequate regional analgesia/anesthesia for labor or operative delivery
10. Discuss the complications of neuraxial anesthesia
1.    a. postdural puncture headache 

1.    b. needle or catheter-induced nerve trauma
1.    c. local anesthesia neurotoxicity
1.    d. epidural abscess
1.    e. epidural hematoma
E. Local Anesthetics
1. General principles of LA pharmacology
1.    2. Describe the criteria for selection of local anesthetics for labor analgesia and anesthesia for obstetric procedures (i.e. forceps, C/S, tubal ligation). Compare the advantages of bupivacaine, levobupivacaine, ropivacaine, lidocaine & chloroprocaine for epidural anesthesia and bupivacaine & lidocaine for spinal anesthesia
1.    3. Describe the effects of adding opioids to local anesthetic agents, including the local-anesthetic sparing effects and side effects of opioids
1.    4. Describe the signs and symptoms of systemic toxicity of local anesthetics, differences in toxicity of various LA agents, and management of toxicity
F. General Anesthesia for Obstetrics
1. Understand the indications for general endotracheal anesthesia in obstetric patients
1.    2. Understand the increased risks of general anesthesia in pregnant vs. nonpregnant patients and the etiology of these risks
1.    3. Discuss the difficult airway algorithm
1.    4. Understand the effect on the neonate of induction to delivery time and uterine incision to delivery time
G. Anesthetic & Obstetric Management of High-Risk Pregnancy
1. Obtain a basic understanding of the obstetric and anesthetic implications for each of the following diseases or obstetric complications
a. hypertensive disorders of pregnancy
1.    b. multiple gestation 
c. preterm labor 
d. abnormal fetal presentations 
e. obstetric hemorrhage
1.    1. placenta previa
2.    2. abruptio placenta 

1.    3. postpartum hemorrhage
f. diabetes in pregnancy
g. substance abuse
h. cardiovascular disease
i. morbid obesity
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 support their own education.
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. Use appropriate communication to allay the anxiety of parturients undergoing anesthesia procedures and surgery under regional anesthesia.
D. Effectively discuss obstetric anesthesia options, including risks and benefits, to parturients presenting to the Labor and Delivery suite.
E. Identify when a language interpreter is required to effectively communicate with a family and utilize available resources to secure adequate language interpretation for the patient.
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. Respond in a timely manner to requests by obstetricians and nurses for obstetric anesthesia services.
D. In a sensitive but effective manner, maintain control of the parturient in severe pain while performing anesthesia procedures.
E. 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. Understand the costs of drugs and equipment used to provide obstetric anesthesia care.
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 each month of this two month 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. 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 the Healthcare Matrix or self-assessment.