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.