Obstetric Anesthesiology Residency

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Overview

All anesthesia residents in the Mount Sinai training program spend 2-3 months of their residency with the division of Obstetric Anesthesiology. Additionally, time is spent on the labor floor throughout the 2nd and 3rd year of your training in the evening as part of your on-call obligation.

The role of the obstetrical anesthesiologist has changed dramatically over the past few decades, from the days when OB anesthesia meant the administration of an inhalation anesthetic, usually delivered by the least trained physician, to the present, when the obstetric anesthesiologist is an integral part of the obstetrical team. We administer anesthesia to antepartum patients, to patients in labor and for cesarean deliveries. The labor floor no longer serves solely as a birthing unit, but also as a critical care area for preterm patients, as well as for parturients with medical complication of pregnancy. The obstetric anesthesiologist serves as the critical care consultant to the obstetrician.

To serve as a consultant requires much more than the ability to establish an epidural or spinal block. A thorough understanding of the physiologic adaptation to pregnancy as well as maternal-fetal interactions is necessary in order to safely manipulate maternal and fetal physiology during the administration of anesthesia. With the increasing recognition of the important role which good anesthetic management can play in the peripartum period, a thorough background in the field of obstetrical anesthesia is more important than ever.

We have well defined objectives for you to accomplish during your time on the labor floor. These objectives are accomplished through clinical experience, bedside teaching, journal club and formal lectures.

  1. In depth understanding of the maternal physiologic changes of pregnancy.
    1. Discuss the maternal cardiovascular adaptation to pregnancy, especially:
      1. Intravascular volume change
      2. Changes in cardiac output during pregnancy
        1. antepartum
        2. peripartum (during labor)
        3. postpartum
      3. Describe aortocaval compression/supine hypotension of pregnancy
        1. describe the normal compensatory mechanisms
        2. describe the potential effects of regional anesthesia
      4. Discuss the potential effects of the cardiovascular changes on the rate of an intravenous or inhalation induction of general anesthesia
    2. Discuss the determinants of uterine blood flow.
      1. Discuss the effects of regional and general anesthesia on uterine blood flow
    3. Discuss the respiratory changes associated with pregnancy.
      1. Discuss the changes in lung volumes and capacities
      2. State the normal values of an arterial blood gas in pregnancy
        1. Explain why they change during pregnancy
      3. Discuss why an inhalation induction may be faster in the pregnant patient
      4. Discuss the effect of pregnancy on the rate of arterial oxygen desaturation during apnea
    4. Discuss the gastrointestinal changes during pregnancy
      1. Discuss the changes in gastric pH and volume
      2. Discuss the Mendelson's syndrome
      3. Discuss aspiration prophylaxis
        1. particulate vs. nonparticulate antacid
        2. H2 blockers
        3. Use of metoclopramide
      4. Discuss changes in liver function during pregnancy
        1. drug metabolism
        2. serum cholinesterase levels during pregnancy
        3. albumen production
        4. production of clotting factors
        5. production of thyroid binding globulin
    5. Discuss the renal changes during pregnancy
      1. Discuss the change in GFR
    6. Discuss the endocrine changes of pregnancy
      1. Thyroid function
      2. Glucose metabolism
      3. Diabetes mellitus
        1. White classification of diabetes
        2. Insulin treatment
        3. Potential effects of maternal hyperglycemia on the newborn
          1. Discuss the potential newborn complications of maternal administration of glucose containing intravenous solutions
  2. Preoperative evaluation of the Obstetric Patient
    1. History and Physical examination
      1. A thorough history and physical exam must be performed on all patients prior to the administration of anesthesia
      2. Determine maternal BP on all patients
        1. discuss the implication of maternal hypertension
      3. Describe the potential airway changes associated with pregnancy
      4. Determine which laboratory tests are indicated and interpret the results
    2. Pre-Anesthetic fetal evaluation
      1. Explain the significance of fetal abnormalities on the anesthetic management of the parturient
      2. Fetal Heart Rate Monitoring
        1. discuss fetal heart rate variability
        2. understand how to identify early vs. late vs. variable decelerations
          1. discuss the significance of each
      3. Monitoring uterine contractions
        1. describe a normal contraction pattern
        2. discuss the significance of uterine hyperstimulation
      4. Fetal acid base status
        1. know the normal values for a fetal scalp blood pH
        2. discuss the significance of a low fetal scalp pH
  3. Understand special problems encountered in obstetrical patients, including:
    1. Potential difficult airway
    2. Increased risk of aspiration
    3. Hypertensive disorders of pregnancy
      1. Discuss the differential diagnosis of hypertension in the pregnant patient
        1. Define chronic hypertension, gestational hypertension, preeclampsia and preeclampsia superimposed on chronic hypertension
        2. Discuss the potential etiology of preeclampsia
        3. discuss the maternal physiologic alterations induced by preeclampsia
        4. distinguish between preeclampsia and eclampsia
          1. discuss seizure prophylaxis with magnesium sulfate
          2. discuss the toxic effects of magnesium therapy and the maternal serum levels of magnesium associated with each
        5. Discuss the treatment of hypertension during preeclampsia
        6. Discuss the potential risks of and benefits of epidural analgesia in the preeclamptic patients
        7. Discuss the potential risks of the induction of general anesthesia in the preeclamptic patients.
    4. Obstetrical hemorrhage
      1. Describe the pregnancy induced changes in coagulation
      2. Define disseminated intravascular coagulation
      3. Discuss the potential hematologic alterations induced by
        1. abruptio placenta
        2. preeclampsia
        3. fetal death-in-utero
        4. amniotic fluid embolus
      4. Discuss the management of DIC
    5. Discuss the implications of valvular heart disease in the parturient
      1. Discuss the risks and benefits of epidural anesthesia in the patient with:
        1. mitral stenosis
        2. aortic stenosis
        3. mitral regurgitation
        4. aortic regurgitation
        5. IHSS
    6. Discuss the management of the pregnant asthmatic
      1. Explain the advantages and disadvantages of epidural anesthesia in the parturient with severe asthma
    7. Discuss the management of the parturient with a neurologic disorder, especially:
      1. Seizure disorder
      2. Multiple sclerosis
      3. Myasthenia gravis
      4. Arterio-venous malformation
      5. Spinal cord injury
      6. Degenerative disc disease
      7. Scoliosis: with or without corrective surgery
      8. Peripheral neuropathy
    8. Discuss the significance of preterm labor
      1. Discuss the implications of regional and general anesthesia for the preterm fetus
      2. What are tocolytic agents?
        1. Name the most commonly used tocolytic agents
        2. discuss their pharmacology
        3. discuss their side effects
          1. effects on maternal glucose metabolism
            1. effect on serum potassium levels
          2. cardiovascular effects
            1. maternal heart rate
            2. maternal cardiac ischemia
            3. pulmonary edema
          3. discuss the anesthetic implications of maternal administration of tocolytic agents
    9. Discuss neonatal resuscitation
      1. Describe the changes in neonatal circulation to allow the fetus to adapt to extra uterine life
        1. Describe the changes in the pulmonary and systemic circulation at birth.
          1. explain the cause of physiologic closure of the ductus arteriosus and the foramen ovale
          2. explain the significance of failure of physiologic closure of these shunts
          3. what factors may predispose the fetus to close these shunts
      2. Discuss the factors stimulating the initiation of respiration in the newborn
      3. Discuss the Apgar Score
        1. describe the initial assessment of the newborn
        2. discuss the management of an infant that demonstrates respiratory depression and bradycardia at birth
        3. discuss the indications for intubation of the newborn infant
        4. discuss the indications for chest compressions in the depressed infant
        5. discuss the use of epinephrine for newborn resuscitation
          1. describe the possible routes of administration of epinephrine
        6. Discuss the indications for volume replacement in the depresses neonate
      4. describe the management of the neonate stained with meconium
        1. describe when intubation is needed and when only suctioning is recommended
  4. Anesthesia for labor and delivery
    1. Discuss non-pharmacologic techniques: advantages and disadvantages
      1. Psycho prophylaxis (prepared childbirth education)
      2. TENS
      3. Acupuncture
      4. Self hypnosis
    2. Discuss the use of parenteral narcotic analgesia
      1. Discuss the advantages and disadvantages of IV narcotic administration
        1. meperidine
          1. discuss the risk of seizure
          2. discuss the metabolite normeperidine
        2. fentanyl
        3. morphine sulfate
        4. agonist/antagonist narcotics: butorphanol and nalbuphene
      2. Discuss the use of IV PCA administered narcotics for labor analgesia
    3. Discuss the use of inhalation analgesia
      1. N2O/O2 mixture
      2. Inhalation of halogenated agents
    4. Epidural and Subarachnoid Labor Analgesia
      1. Discuss the advantages and disadvantages of neuraxial labor analgesia
        1. discuss the advantages and disadvantages of epidural analgesia
        2. discuss the advantages and disadvantages of spinal analgesia
        3. discuss the advantages and disadvantages of combined spinal/epidural analgesia
      2. Discuss the site of action of local anesthetics when:
          1. Administered into the epidural space
          2. Administered into the subarachnoid space
      3. Discuss the site of action of narcotics when administered into the:
          1. Epidural space
          2. Subarachnoid space
      4. Discuss the pharmacology of the following anesthetics when administered either into either the epidural or subarachnoid space
        1. bupivacaine
        2. levobupivacaine
        3. ropivacaine
        4. chloroprocaine
        5. meperidine
          1. discuss the local anesthetic effects of meperidine
        6. fentanyl
        7. sufentanil
      5. Discuss local anesthetic toxicity
        1. Discuss the signs and symptoms of an intravenous injection of local anesthetic
        2. discuss the cardiac toxicity of local anesthetics
          1. Describe the relative cardiac toxicity of bupivacaine vs. ropivacaine vs. levobupivacaine vs. lidocaine vs. chloroprocaine
            1. Discuss the treatment of local anesthetic cardiac toxicity
        3. Describe the CNS toxicity of local anesthetics
          1. Discuss the management of local anesthetic induced seizures
      6. Discuss the complications of an incidental dural puncture during placement of an epidural
        1. Describe how to recognize a high spinal vs. total spinal anesthetic
          1. Describe the etiology of respiratory arrest with a total spinal anesthetic
          2. Discuss why the pupil will be dilated after total spinal anesthesia
        2. Discuss the diagnosis of a dural puncture headache
          1. Discuss the management of a dural puncture headache
            1. Discuss epidural blood patch
              1. discuss the complications of an epidural blood patch
              2. discuss prophylactic epidural blood patch
      7. Discuss the risk of neurologic injury after placement of a regional anesthetic.
        1. discuss backache after regional anesthesia
        2. discuss nerve root injury after epidural or spinal placement
        3. discuss spinal cord injury after epidural or spinal anesthesia
  5. Anesthesia for Cesarean Section
    1. Discuss the advantages and disadvantages of epidural, spinal or general anesthesia for cesarean section
    2. Discuss the local anesthetics, concentrations and doses, used for either epidural or spinal anesthesia for cesarean section
    3. Describe the preparation of the pregnant patient for general anesthesia
      1. Discuss the impact of the GI changes in pregnancy on the risk of maternal aspiration of gastric contents after the induction of general anesthesia
      2. Explain the technique of rapid sequence induction
        1. Explain why this is necessary in the term pregnant patient
        2. Discuss the rate of oxygen desaturation during a rapid sequence induction of GA in the pregnant patient
      3. Discuss the induction of general anesthesia
        1. Discuss the advantages and disadvantages of the following induction agents
          1. Etomidate
          2. Pentothal
          3. Propofol
          4. Ketamine
            1. Know the induction dose of each in the pregnant patient
      4. Discuss the effects of regional anesthesia vs. general anesthesia on uterine blood flow
      5. Discuss the appropriate anesthetic choices for emergency cesarean section for
        1. non-reassuring fetal heart rate tracing
        2. maternal hemorrhage
        3. double set up
    4. Discuss techniques of postoperative analgesia after cesarean section
      1. Parenteral narcotics
        1. intermittent dosage or IV PCA
      2. Epidural narcotics: with or without local anesthetics
        1. preservative free morphine
        2. epidural infusion of narcotics/local anesthetic solutions
      3. Subarachnoid narcotics
        1. preservative free morphine
        2. other narcotics
  6. Understand and prepare the equipment necessary to care for the peripartum patient
  7. Care for the pregnant patient during the peripartum and/or perisurgical period
    1. Perform an appropriate history and physical exam
      1. Order lab investigations when indicated
    2. Make an appropriate anesthetic plan
      1. Labor analgesia
        1. discuss the contraindications to the placement of a neuraxial block
        2. Describe the appropriate times to administer
          1. Epidural labor analgesia
          2. Spinal labor analgesia
          3. Combined epidural-spinal analgesia
          4. Intravenous narcotics
        3. Discuss appropriate maternal and fetal monitoring after placement of an epidural &/or spinal labor analgesic
      2. General anesthesia
        1. Establish appropriate monitoring prior to the induction of general anesthesia
        2. Decide upon an appropriate induction technique
      3. Understand and treat the complications of anesthetic interventions, such as:
        1. maternal hypotension
        2. high or total spinal
        3. failed or difficult intubation
        4. inadvertent dural puncture
        5. local anesthetic overdose or intravascular injection
          1. discuss the management of local anesthetic induced seizure
          2. discuss the management of local anesthetic induced cardiac toxicity
          3. discuss the management of inadequate anesthesia or analgesia
    3. Provide care for the newborn if needed, including neonatal resuscitation

Formal lectures administered on a monthly basis

  1. Physiologic adaptation to pregnancy
  2. Neonatal resuscitation
  3. Anesthesia for toxemia
  4. Obstetric hemorrhage
  5. Complications of Obstetric Anesthesia
  6. Fetal heart rate monitoring
  7. Management of postdural puncture headache
  8. Labor analgesic techniques: epidural vs. combined spinal-epidural
  9. Local anesthetics
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