OBSTETRIC ANAESTHESIA
Based on: THE CCT IN ANAESTHESIA III: Competency Based Specialist Registrar Years 1 and 2 Training and Assessment
This is a ‘Key Unit of Training’ in which SpR 1/2 trainees should spend the equivalent of at least 1 month of training and, normally, not more than 3 months. Obstetric anaesthesia and analgesia is the only area of anaesthetic practice where two patients are cared for simultaneously. Pregnancy is a physiological rather than a pathological state. Patient expectations are high and the mother expects full involvement in her choices of care. The majority of the workload is the provision of analgesia in labour and anaesthesia for delivery. Multidisciplinary care for the sick mother is increasingly important and highlighted.
Knowledge
Anatomy and physiology of pregnancy Physiology of labour Placental structure and mechanisms affecting drug transfer across the placenta Basic knowledge of obstetrics Gastrointestinal physiology and acid aspiration prophylaxis Pharmacology of drugs relevant to obstetric anaesthesia Pain and pain relief in labour Emergencies in obstetric anaesthesia: Pre-eclampsia, eclampsia, failed intubation, major haemorrhage, Maternal resuscitation, amniotic fluid embolus, total spinal Use of magnesium sulphate Incidental surgery during pregnancy Assessment of fetal well being in utero Thromboprophylaxis Feeding / starvation policies Influence of common concurrent medical diseases Management of twin pregnancy Management of premature delivery Maternal morbidity and mortality Management of difficult or failed intubation Maternal and neonatal resuscitation Legal aspects related to fetus
Skills
Assessment of pregnant woman presenting for anaesthesia / analgesia Epidural / subarachnoid analgesia for labour Management of complications of regional block and of failure to achieve adequate block Epidural and subarachnoid anaesthesia for Caesarean Section, and operative deliveries Conversion of analgesia for labour to that for operative delivery General anaesthesia for Caesarean Section Airway management Management of the awake patient during surgery Ability to ventilate the newborn with bag and mask Anaesthesia for interventions other than delivery Post-delivery pain relief Management of accidental dural puncture and post-dural puncture headache Recognition of sick mother High dependency care of obstetric patients Optimisation for the ‘at risk’ baby
Attitudes and behaviour
To be aware of local guidelines in the obstetric unit To communicate a balanced view of the advantages, disadvantages, risks and benefits of various forms of analgesia and anaesthesia appropriate to individual patients To communicate effectively with partner and relatives To help deal with disappointment To be involved in the initial management of complaints To communicate effectively with midwives To obtain consent appropriately To keep good records To identify priorities To attempt by conscientious care to recognise problems early To allocate resources and call for assistance appropriately To be aware of local audits and self audit
Workplace training objectives
Within the obstetric team, the trainee should play a full part; communicating effectively about anaesthetic and analgesic techniques used in obstetrics and developing organisational skills. They should consolidate clinical management of common obstetric practice but recognise and treat common complications exercising proper judgement in calling for help.
Recommended local requirements to support training
• Training should normally be provided in units carrying out at least 2,000 deliveries annually. • There should be at least 1 consultant anaesthetic session allocated for every 500 deliveries. (In units with a frequent turnover of inexperienced trainees, with a higher than average epidural or Caesarean Section rate and/or a substantial number of high risk cases, sessions above this minimum will be required). • Local protocols should be available to guide trainees in the management of common obstetric emergencies based on the individual units staffing and local support. • Appropriately trained assistance for the anaesthetist (to NVQ level 3 in Operating Department Practice or in possession of the appropriate ENB qualification) must be locally available whenever a trainee anaesthetist is required to manage a patient during an operative delivery. The person providing this assistance to the anaesthetist should have no other duties at that time. • Access for patients to critical care facilities must be immediately available at all times. • Appropriate anaesthetic ‘bench books’ should be available within the delivery suite.
ArticleDate:20061028
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