Obstetric Anesthesiology Rotation
Curricular Milestones
Ensure readiness of Labor & Delivery ORs and emergency equipment.
1. Confirm machine, monitors, suction prepared.
2. Check availability of LMA/ bougie (in OR) and difficult airway supplies (in
workrooms)
3. Confirm presence and expiration time/ date of emergency drugs on/in cart.
4. Ensure resuscitation equipment in OR (level I)
Perform pre-operative assessment for low-risk parturient
1. Adequate presentation to supervisor
2. Obtain relevant medical history and medication lists including previous anesthetics
and previous pregnancies/ deliveries
3. Perform relevant physical exam including airway exam
4. Summarize pertinent patient diagnostic data
5. Determine if additional diagnostic tests are needed and order/ interpret as
appropriate
6. Understand ASA classification system and assign the appropriate class
7. Understand impact of physiologic changes of pregnancy
Perform pre-operative assessment for high-risk parturient
1. Adequate presentation to supervisor
2. Obtain relevant medical history and medication lists including previous anesthetics
and previous pregnancies/ deliveries
3. Perform relevant physical exam including airway exam
4. Summarize pertinent patient diagnostic data
5. Determine if additional diagnostic tests are needed and order/ interpret as
appropriate
6. Understand ASA classification system and assign the appropriate class
7. Understand impact of physiologic changes of pregnancy
8. Recognize both fetal and maternal factors leading to high risk pregnancy
9. Attend MFM clinic case discussions and antepartum anesthetic consultation as
needed
10. Attend and contribute to multidisciplinary care conferences as appropriate
11. Communicate concerns about anticipated patient issues to all care team members
(anesthesia, OB, nursing) and patient
Choice of and consent for anesthesia
1. Understand the choice of general versus regional anesthesia, including options
within regional anesthesia
2. Apply patient medical and obstetric history and physiologic changes of pregnancy to
anesthetic plan
3. Understand how the obstetric plan impacts the anesthetic plan and discuss
anticipated issues with obstetric team and L&D nursing
4. Identify risks and benefits of anticipated anesthetic technique and discuss with
patient and family members
5. Identify potential ethical issues (e.g. Blood transfusion refusal, Do Not Resuscitate,
etc.)
Neuraxial procedures for laboring patients
1. Understand the indications and contraindications for neuraxial anesthesia
2. Understand implications of physiologic changes of pregnancy on anesthetic plan.
3. Appreciate the pros and cons for spinal, epidural, and combined spinal epidural and
make the appropriate choice given patient factors.
4. Understand the timing of regional blockade on technique and medication choices
(latent v. active phase of labor, spontaneous v. induced labor, etc)
5. Administer premedication as appropriate
6. Maintain sterile technique
7. Appropriate choice of local anesthetic, narcotic and adjuvants as appropriate for
initiation of regional blockade.
8. Successfully initiate epidural and combined spinal-epidural analgesia.
9. Monitor patient before, during and after regional blockade.
10. Communicate with patient, family member and nurse during procedure.
11. Understand when test dose of epidural catheter is needed and choose test dose
appropriately.
12. Respond appropriately to acute complications of neuraxial placement.
Neuraxial procedures for cesarean delivery
1. Understand the indications and contraindications for neuraxial anesthesia
2. Understand implications of physiologic changes of pregnancy on anesthetic plan.
3. Appreciate the pros and cons for spinal, epidural, and combined spinal epidural and
make the appropriate choice given patient factors
4. Ensure appropriate pre-medication administered.
5. Understand the impact of elective v. urgent v. emergency cesarean on anesthetic
technique.
6. Understand the impact of fetal and maternal status on dosing of epidural medication
for cesarean delivery.
7. Maintain sterile technique during neuraxial procedures.
8. Appropriate choice of local anesthetic, narcotic and adjuvants as appropriate for
initiation of regional blockade.
9. Successfully initiate single shot spinal and combined spinal-epidural surgical
anesthesia.
10. Monitor patient before, during and after regional blockade.
11. Position patient appropriately following procedure.
12. Respond appropriately to acute complications of neuraxial placement.
Perform anesthetics for antepartum and postpartum procedures
1. Understand principles of anesthesia for non-obstetric surgery during pregnancy
2. Choice of appropriate anesthetic technique, depth of anesthesia, and medication for
cerclage placement and removal, external cephalic version, post-partum tubal
ligation and D&C.
3. Recognize advantages and disadvantages of performing such procedures in a labor
room versus the operating room.
4. Coordinate fetal monitoring for procedure and plan for delivery (if continuous
monitoring) with surgeons, obstetricians and nursing.
Manage general anesthetic for cesarean delivery
1. Application of standard monitors
2. Understand indications for elective cesarean under general anesthesia
3. Choice of appropriate induction and maintenance method and agents
4. Utilize operating room staff and resources for timely start of emergency cesarean
5. Communicate with obstetric team during induction of anesthesia and intubation.
6. Recognize possibility of difficult airway and risk of aspiration in pregnant patient
7. Utilize advanced airway devices as needed to secure airway
Demonstrate knowledge and use of common obstetric medications.
1. Understand pharmacology for uterotonics (oxytocin, methylergonovine, carboprost,
misoprostol).
2. Administer appropriate uterotonics in case of postpartum hemorrhage
3. Communicate with obstetricians and nursing regarding need for uterotonics/
resultant effect
4. Anticipate and treat adverse effects
5. Understand dosing, side effects, hemorrhage risk, indications, contraindications for
use of magnesium sulfate in pregnant patients
6. Aware of commonly used tocolytics such as terbutaline, nifedipine, nitroglycerin
and understand pharmacology, advantages, disadvantages and potential anesthetic
implications of each
Demonstrate knowledge and use of common obstetric anesthesia medications.
1. Recognize options and pharmacokinetics of local anesthetic and narcotics for
neuraxial blockade initiation, and maintenance and advantages/ disadvantages
depending on clinical situation.
2. Administer appropriate neuraxial local anesthetic, narcotic or combination.
3. Utilize neuraxial adjuvants as appropriate
4. Understand adverse effects of neuraxially administered medications.
5. Anticipate toxic dose of local anesthetic and recognize symptoms of LAST
6. Understand treatment protocol and location of treatment resources at all L&D
locations where local anesthetic is administered.
Manage anesthesia for complicated deliveries
1. Compose anesthetic plans and provide anesthesia for deliveries of multiple
gestations, trial of labor after cesarean (TOLAC), operative/ assisted vaginal
delivery, and/or suspected abnormal placentation.
2. Coordinate timing of delivery and anticipated mode of delivery with obstetric and
nursing teams.
3. Communicate any concerns regarding complicated delivery patients with obstetric
and nursing team
Manage anesthetic care for high-risk maternal conditions
1. Consider pathophysiology of hypertensive disorders of pregnancy and their
treatment in formulating anesthetic plan.
2. Recognize reasons for IUFD and implications on maternal status
3. Modify anesthetic plan and technique as needed for maternal diabetes, super
morbid obesity.
4. Apply ASRA guidelines for neuraxial procedures for anticoagulated patients to
pregnant population
5. Perform antepartum and intrapartum care for patients with placenta previa/ vasa
previa.
6. Understand causes of thrombocytopenia in pregnant patients and counsel patient/
family/ providers about implication for anesthetic plan.
7. Interpret laboratory results including coagulation studies and order additional
testing as appropriate.
Maintenance of analgesia/ anesthesia for labor and management of intrapartum
issues/ events
1. Assess adequacy of labor analgesia and provide “top-offs” and changes in PCEA
settings as appropriate.
2. Decide when replacement of epidural catheter is necessary, council patients
accordingly, and perform procedure.
3. Perform troubleshooting techniques for possible poorly functioning epidural
catheter.
4. Understand basic electronic fetal monitoring interpretation and discuss changes in
fetal status with nursing/ obstetric teams.
5. Maintain accurate anesthetic records for laboring patients and document all patient
interactions, including follow-up results to “top-offs”.
6. Communicate any perceived issues with supervising staff and all present anesthesia
providers.
Coordinate within labor and delivery environment
1. Utilize anesthesia technicians, nursing staff and pharmacy staff as appropriate
2. Maintain accurate records of controlled substance administration
3. Help arrange transfer of patients to and from L&D to IR and ICU as needed
4. Prioritize procedures and distribute/ coordinate anesthesia manpower
appropriately
5. Demonstrate appropriate interactions with challenging or demanding patients.
Management of unanticipated obstetric complications
1. Identify, formulate a differential diagnosis, and treat postpartum hemorrhage
2. Enact massive transfusion protocol, coordinate resulting hospital wide resources,
and lead maternal resuscitation
3. Place invasive monitors as indicated.
4. Understand pathophysiology of rare obstetric complications such as embolic
disorders of pregnancy (AFE, VAE, VTE), uterine inversion, seizure from eclampsia,
etc.
5. Understand etiologies and treatment for uterine tachysystole, provide treatment as
requested and be prepared if no resolution.
6. Know ACLS guidelines for pregnant patients
7. Maintain appropriate contact with supervising staff and other anesthesia providers
8. Recognize when patients require change in post-partum disposition (e.g. ICU
monitoring, continued artificial airway +/- mechanical ventilation) and
communicate this to supervising staff as well as surgical and OR nursing team
9. Provide hand-off to ICU staff in cases where patients are taken directly to ICU postop
Management of unanticipated obstetric anesthesia complications
1. Recognize and provide timely treatment for common side effects/ complications of
OB anesthesia procedures such as hypotension, pruritus and localized back pain.
2. Diagnose and replace intravascular catheter.
3. Recognize unintentional dural puncture with Tuohy needle, discuss complication
with supervising staff.
4. Manage intrathecal catheter (both inadvertent catheter placement and post-wet
tap) and clearly label catheter and anesthesia cart.
5. Disclose complication to patient and discuss implications with patient, nursing,
obstetric team and other anesthesia providers.
6. Provide follow-up care after intrathecal catheter and ensure patient has anesthesia
contact information.
7. Educate patient about epidural blood patch and perform EBP.
8. Diagnose high spinal blockade and provide supportive care.
Postoperative and PACU care for pregnant patients
1. Prepare the patient for emergence from general anesthesia
2. Understand criteria for extubation, and risks associated with airway manipulation
in parturients
3. Transfer the patient to the PACU and provide smooth transition and handoff to the
PACU staff
4. For laboring patients, determine when/ why epidural catheters should be left in
place (and if running or not) and communicate with nursing and obstetric teams
5. Ensure intact removal of epidural catheters by anesthesia or nursing staff
6. Manage common postoperative problems (headache, backache, urinary retention)
7. Diagnose postpartum neuropathy, understand most common causes and educate
patients regarding likely etiology, clinical course and time to resolution.
8. Help coordinate follow-up for patients with postpartum neurologic (motor) deficit
9. Perform post-operative patient visits and document patient interactions in medical
record
Neonatal Resuscitation
1. Understand role of anesthesiologist in neonatal resuscitation
2. Communicate with nursing and pediatric teams in cases where anesthesiology help
with NRP is needed
3. Recognize potential ethical dilemmas in anesthesiology participation in NRP when
only one provider is available for both maternal and fetal care.
4. Be familiar with current NRP guidelines