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OBSTETRIC ANESTHESIA RESIDENT HANDBOOK
RESIDENT SCHEDULE
OPERATING ROOM SET UP
PREANESTHETIC EVALUATION
HIGH RISK CONSULT SERVICE
ASEPTIC TECHNIQUE
EPIDURAL PLACEMENT AND MAINTENANCE
COMBINED SPINAL EPIDURAL (CSE) PLACEMENT
CESAREAN DELIVERY WITH IN SITUEPIDURAL
TOPPING OFF LABOR EPIDURALS
CATHETER PULLS
SUBARACHNOID BLOCKS
COMPLICATIONS OF NEURAXIAL TECHNIQUES
OBSTETRIC ANESTHESIA CURRICULUM
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RESIDENT SCHEDULE
The resident schedule is as follows: on months when 2 residents are rotating on theservice, one will be designated the a.m. resident and the other will be the p.m.
resident. The a.m. resident should arrive no later than 6:45 and will stay until 3 p.m.;the other resident will arrive at 11 a.m. and stay until 7 p.m. There is often a flurry
of epidural placements between 6:30 and 7:00 a.m., so the early resident mightconsider coming earlier when possible.
Each week the a.m. and p.m. resident will alternate. You are responsible for agreeing
who will be the a.m. and p.m. resident the first week and for alternating thereafter.The first day on the service both residents can arrive at 6:45 so that the more senior
resident can orient the other. When only one resident is on the rotation, he/sheshould arrive no later than 6:45 a.m. and stay until 5 p.m. In the near future, we
hope to have overnight call facilities for residents, and at that time we will tweak the
schedule once again to ensure optimal exposure to procedures on the L&D ward.
Please note that you are responsible for contacting both Patty Burke and the staffmember on L&D if you have an unanticipated emergency or illness and are unable to
get to work. The same applies if you request an additional vacation day that was not
originally scheduled.
When the a.m. resident arrives, he/she should check the anesthesia machine and
ensure that emergency drugs and equipment for the administration of a generalanesthetic are immediately available. The cases for the day are usually posted on the
white bulletin board; scheduled labor inductions are listed in a binder at the nursingstation or, if the patient is already inhouse, on the bulletin board. The CRNA on L&D
can also provide updates for the days schedule.
Daily resident duties include: attend the safety rounds at 7:30 a.m. each morning
in the 2nd floor neonatal conference room, when possible; fill out the preanesthesia
evaluation papers on each patient requesting an epidural or scheduled for Cesareandelivery, cerclage, tubal ligation, etc. (the packet of papers is usually in the patients
chart or on the clipboard in the anesthesia work room); place epidurals onceproperly trained and prepared, and fill out all the relevant paperwork; troubleshoot
and topoff epidurals, as needed; provide neuraxial or general anesthesia for
operative procedures, remaining with the patient and charting appropriatelythroughout; attend all lectures offered by staff, colleagues, and fellows; perform
postoperative visits on all patients from the preceding day (a list of patients will be
provided); and provide continuity of care for all antepartum patients (these are thepatients being observed on the floor whose status should be reassessed on a daily
basis). If two residents are available during the hours between 11 a.m. and 3 p.m.(when shifts overlap), one will be expected to run the floor, placing and
troubleshooting epidurals, while the other is in charge of surgical cases. Antepartum
and postpartum visits can be divided between residents, or residents can alternatethese duties week by week.
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In addition to the above duties, each resident is responsible for making a
PowerPoint on a subject of interest for presentation during the final week on therotation. We will also assign a series of Jackpot questions at the beginning of the
rotation; we expect you to research the answers and be prepared to answer thesequestions at a designated Jackpot answer session each week (below is a list of
resources to aid in your research). Further, when time permits, you will be expectedto take over surgical procedures already underway, relieving the CRNA andassuming responsibility for those obstetric patients in the operating suites. Finally,
occasionally you will be asked to perform preoperative assessments on both high
risk parturients and nonobstetric patients scheduled for outpatient surgery atTulane Lakeside in the anesthesia preoperative evaluation clinic on the 1stfloor.
These preoperative evaluations require your familiarity with preoperativeguidelines, anesthetic implications of a variety of disease processes, and with
further workup algorithms that might be necessary to optimize a patient for
surgery. The preoperative evaluation clinic provides a good learning opportunity,particularly in preparation for the Oral Boards.
The L&D ward is marked by peaks and lulls; residents should take advantage ofdowntime by studying, reading, preparing the final PowerPoint presentation, and
answering the Jackpot questions. The third floor office has several texts andquestion books, as well as three computers with PowerPoint capacity. Please take
advantage of these facilities for study, research, etc.
Finally, a very informative and recently updated reference book to help guide you
during this rotation is Obstetric Anesthesia Handbookby Sanjay Datta, BhavaniShankar Kodali, and Scott Segal. It is available at Amazon and other online
companies. You should also be intimately familiar with the 2007 ASA Practice
Guidelines for Obstetric Anesthesia (seeAnesthesiology2007;106:84363 or simplyGoogle ASA Obstetric Anesthesia Guidelines; these guidelines are also printed in
the back of Chestnuts Obstetric Anesthesia text). Other resources you may find
helpful include: Chestnuts Obstetric Anesthesia: Principles and Practice, 4th Ed;Clinical Anesthesiologyby Morgan, Mikhail and Murray (with particular emphasis on
the Local Anesthetics and Obstetric Anesthesia chapters); andAnesthesia Review: AStudy Guide to Anesthesia and Basics of Anesthesia by Lorraine Sdrales and Ronald
Miller (again, with emphasis on the Local Anesthetics and Obstetric Anesthesia
chapters). These and other texts, including LongneckersAnesthesiology, MillersAnesthesia: 2 Volume Set , and Barashs Clinical Anesthesia are in the 3rd floor office,
although I encourage you to purchase the Obstetric Anesthesia Handbook.
OPERATING ROOM SET UP
Each morning and after each case, the anesthesia machine and all equipment must
be checked and left ready for any emergency that might arise.
The following items must be immediately available and ready to use:
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Anesthesia machine with breathing circuit (that has been tested for leaks) and
mask
BP cuff, EKG, and SpO2 cable
Laryngoscopes and blades (be sure to check each handle and blade)
Styletted ETT of all sizes (6.0, 6.5, 7.0) Immediately available ephedrine, phenylephrine, and succinylcholine. Atropine,
glycopyrrolate, and epinephrine should be readily accessible
A secure, readily available induction agent and syringe
Working suction with tip attached
Ambu bag
Oral airways
Stethoscope
A fully stocked obstetric hemorrhage cart and difficult airway cart are immediately
available in the OR common area
PREANESTHETIC EVALUATION
Patients on the L&D floor are to be seen and evaluated upon nurse or obstetricianrequest. In addition, we often elect to evaluate all patients considered high risk as
soon as possible, including patients scheduled for trial of labor after Cesarean
(TOLAC), obese patients, patients with known or suspected difficult airways,multiplegestation parturients, severe preeclamptics, etc.
A focused H&P should include age, gravid and para state, weeks gestation, any
complications of current pregnancy, reason for C/S (if applicable), reason for prior
C/S (if applicable), previous anesthetics, height, weight, allergies, comorbidities,
airway, heart and lung examination, any relevant labs (platelets for a patient withknown gestational thrombocytopenia, platelet disorder, HELLP, or clinical history ofbleeding; urine protein for patients with preeclampsia; blood glucose for patient
with DM, etc.), NPO status, and anesthetic assessment and plan. A baseline maternal
blood pressure and fetal heart tones (FHTs) should also be documented.
For review of systems, it is important to evaluate whether patients with
preeclampsia have visual changes, edema, abdominal pain, headache, or any signs ofeasy bleeding/bruising. Ask all parturients about GERD, as well as n/v, SOB, CP, and
palpitations, when appropriate.
HIGH RISK CONSULT SERVICEIn concert with the Obstetrics Department, we recently launched a highrisk consultservice. Obstetricians have been asked to identify parturients considered high risk
and send them for an anesthesia consult in advance of the estimated date of
confinement (EDC). Highrisk patients include, among others, super morbidly obesewomen with other comorbidities, patients with severe scoliosis, patients at risk for
hemorrhage (previa, accreta, percreta, for example), patients with bleedingdisorders or congenital heart disease, etc. This consult service also gives us an
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opportunity to meet patients with anesthesia concerns, including those with a
history of difficult epidural placement, in advance. Our goal is to assess thesepatients, order any relevant consults or further workup, and craft an anesthetic
assessment and plan, which, in turn, will be circulated among all relevant parties.Residents will, on occasion, be asked to conduct a full H&P on highrisk patients in
the preoperative evaluation clinic on the 1st
floor at Tulane Lakeside, present theirfindings to the staff or fellow, and dictate a report. We will provide a template fordictation and ensure access to the dictation services.
Importantly, remember to ask the patient to inform the anesthesiologist that shewas seen in the highrisk clinic when she comes in for her delivery. Also, record the
name of the obstetrician on the H&P, the patients telephone number (in the eventthat we have to contact her for followup), and the EDC on the H&P. We have
separate binders for highrisk patients, both those to be delivered and those
already delivered, in the anesthesia stock room on the L&D floor. Printed copies ofour dictation or of our H&P are to be placed in alphabetic order in the to be
delivered binder until the patient presents for delivery, at which time we can pullthe copies and attach them to the patients clipboard.
ASEPTIC TECHNIQUEInfectious complications of neuraxial techniques are rare, but on the rise. The
causative organism in the case of meningitis is most often traced to the
nasopharnygeal bacteria (specifically, alphahemolytic streptococci) of theanesthesia provider. As a result, it is considered standard of care to wear a mask, as
well as sterile gloves and a scrub hat, while performing neuraxial procedures. It isalso reasonable to consider routinely placing a cap on the patient. Chloroprep has
been proven to be superior to Betadine in terms of its bactericidal properties. It is
not yet available in (or FDA approved for) spinal and epidural kits, but can bedropped onto your open sterile field if you prefer to use it for prepping the patients
back. Finally, handwashing has been shown to be the most effective way to prevent
the spread of nosocomial infection; changing gloves is not a substitute for washinghands with each new patient contact. For more information, please refer to Terese
Horlocker and Denise Wedels Infectious complications of regional anesthesia inBest Practice & Research Clinical AnaesthesiologyVol. 22, No. 3, pp. 451475, 2008.
EPIDURAL PLACEMENT AND MAINTENANCEAfter your H&P is complete and you have withdrawn the appropriate epidural
medications (more below) and pressors (ephedrine and phenylephrine), roll one of
the two epidural carts into the patients room (one cart is located in the anesthesiastock room; the other is in the common area between the ORs). Make sure that the
cart is properly stocked before using it. The epidural solution of 0.1% bupivacainewith 2 mcg/mL of fentanyl and the ephedrine are located in the Pyxis in the OR
common area. Premade syringes of a loading dose are located in the anesthesiastock room, along with a premade solution of phenylephrine at a concentration of
100 mcg/mL.
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Confirm that the patient has a working IV and consider either a crystalloid preload
(this is controversialplease refer to the ASA Obstetric Anesthesia Guidelines and
to your attending staffs clinical judgment) or coload.
Although we do not routinely administer aspiration prophylaxis for epidural
placement, it is reasonable to consider giving Bicitra 30 mL PO before starting,
particularly if there is any concern that the patient may go for an urgent/emergent
Cesarean delivery (for example, if there is fetal distress or imminent breechdelivery).
Nursing guidelines (AWHONN) state that a nurse should be present during all
epidural placements in order to monitor both the mother and the fetus and in the
event of unanticipated complications. The ASA Obstetric Anesthesia guidelines state:the fetal heart rate should be monitored by a qualified individual before and after
administration of neuraxial analgesia for labor.
Wash hands; wear gloves, hat and mask.
The patient can be placed in either lateral or seated position during placement. The
former may provide greater comfort, decrease patient movement, and decrease theincidence of intravascular cannulation, while the latter position may facilitate
visualization of the patients anatomical landmarks.
Our epidural kits are equipped with Tuohy needles (we currently stock both 17 G
and 18 G needles); either loss of resistance to air or saline (per your comfort level
and your staffs preference) is suitable for advancing into the epidural space.
Warn the patient of the possibility of a paresthesia before threading the catheter.
The literature states that threading the catheter 35 cm into the epidural spacereduces the incidence of unilateral block, intravascular cannulation, paresthesias,
and catheter knotting. Defer to your staff s judgment when threading the catheter.
Note that it is important to document both the distance to the epidural space andwhere the catheter is taped to the skin.
Place the patient in a slight lateral tilt during epidural dosing; the nurses are very
helpful with positioning, and most rooms are equipped with hip rolls/pillows
specifically for this purpose.
The catheter should be tested with 3 mL increments of local anesthetic with
frequent negative aspirations (i.e., draw back the syringe before each injection to
ensure that there is no blood backflow) and frequent blood pressure readings. Thetraditional test dose with 1.5% lidocaine with epinephrine can be substituted by
administering your choice of local anesthetic solution (see next bullet)
incrementally with frequent negative aspirations.
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Once subarachnoid and intravascular catheter placement have been ruled out, the
full loading dose should be administered in slow, divided doses with frequent
negative aspirations. We currently have 2 loading dose options: a premade syringewith 0.0625% bupivacaine with 100 mcg of fentanyl can be administered, followed
by patientcontrolled epidural anesthesia (PCEA) pump settings of 12 mL/hour,with 4 mL bolus every 10 minutes (12/4/10). Alternatively, withdraw 20 mL of theepidural solution (0.1% bupivacaine solution with 2 mcg/mL) from the bag and
administer in divided doses, followed by PCEA settings of 8 mL/hour, with bolus of8 mL every 15 minutes (8/8/15).
Evaluate the quality and level of the block, observing the patient for roughly 15
minutes and recording 3 blood pressure readings.
Our new Hospira PCEA pumps are excellent for delivering labor analgesia and are
fairly simple to use. They require special tubing, so be sure to grab the dedicated
tubing from the stock room before you enter the patients room; alternatively, extratubing is stocked in the epidural placement carts. Each pump is encased in a hard
plastic case/lockbox and has a key (attached via a rubberband) for securing ourepidural solutions. When programming the pump, first plug it in (the nurses
routinely unplug the pumps after deliveries). Next, press the ON/OFF button. Thepump performs a self test and asks that you press ENTER. Next you get 3 program
options: press #3 (CLEAR PROGRAM, SHIFT, and HISTORY). If it says KEYPAD
LOCKED, press OPTIONS and then press # 3 (FULL LOCK). It then asks you to enterthe lock sequence number; to unlock the pump so that you can reprogram it, enter
13000. Then resume programming, electing CLEAR PROGRAM, SHIFT, and
HISTORY. It will say CLEARING PROGRAM. Next it asks whether you want
continuous, bolus only, or continuous + bolus. Choose #3 (CONT + BOLUS). The nextpage asks you to set the rate and press ENTER WHEN DONE. Next it asks youwhether you want to program a loading dose. Say NO. The next page asks for the
BOLUS dose; set it and press ENTER. The following page asks for BOLUS LOCKOUT;
enter 10 or 15 minutes, depending on your regimen, and press ENTER. Next it asksfor your hourly limit; select #4 (NO LIMIT SELECTED). Next it asks you to enter
CONTAINER SIZE; enter 250 mL if you havent removed any solution from the bag;
enter 230 mL if you have withdrawn a 20 mL loading dose from the bag. The nextpage is for AIR SENSITIVITY. Press 2 mL (option #2). Then theres a program review
option, and you must press the down arrow to review the program parameters youhave selected. When the review is complete, press ENTER. The program will be
saved and you must press START to begin the infusion.
Program the PCEA pump at either 12/4/10 or 8/8/15, depending on which loading
dose you administered, and explain to the patient that she should press the patientcontrolled analgesia button as often as she likes to get a little extra medicine.
Explain that the pump is programmed and will not deliver too much medicine or
permit an overdose (that is, it will deliver the bolus only every 10 or 15 minutes,
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depending on your settings, regardless of how often she presses the button).
Emphasize the importance of pressing the button as soon as she feels the slightestdiscomfort in order to optimize her pain management. Several studies have
demonstrated broader, improved spread of the epidural solutions when the patientuses the PCEA button; faster boluses are thought to be superior to a continuous slow
infusion without the intermittent boluses.
After an epidural has been placed, please write the time of placement on the board
next to patients room number (write, for example, Epi at 6:45 am).
COMBINED SPINAL EPIDURAL (CSE) PLACEMENT
CSEs are ideal for multiparous parturients who present at an advanced stage of
dilation, as well as for laboring patients who present in pain early in labor. They are
also routinely performed for C/S (with higher doses of local anesthetic and opioids)when the length of the surgery might outlast the duration of a spinal (e.g., for repeat
C/S with tubal ligation, an extremely obese patient whose surgery might take a long
time, etc.). That said, the decision to use a particular analgesic or anesthetictechnique should be individualized, based on obstetric or fetal risk factors, the
preferences of the patient, and the judgment of the anesthesiologist. Discusswhether a CSE is appropriate for your patient with staff.
For a laboring CSE, we are having pharmacy provide premade syringes with 1 mL
of 0.25% bupivacaine and 15 mcg of fentanyl. Check out the premade syringe from
the anesthesia stock room refrigerator. Note that these syringes are not currentlyavailable and that several solutions with varying amounts of local anesthetic and
opioid are suitable for a CSE; your attending staff will guide you on this front.
Identify the epidural space with a Touhy needle via the loss of resistance (LOR)technique. LOR to either air or saline is appropriate; some prefer air to ensure thatdroplets upon dural puncture are CSF and not saline seeping out of the epidural
space.
Pass the 25G Whitacre spinal needle through the Touhy needle until you
appreciate a give or dural pop. Then withdraw the stylette from the 25GWhitacre and, once CSF is visualized, attach a sterile 3 mL syringe in which you have
drawn up your solution of 0.25% bupivacaine and fentanyl, and inject without prioraspiration. Using a non Luerlok (i.e., sliptip) 3 mL syringe may facilitate injection of
the CSE solution, as you can avoid having to twist the syringe to the 25G Whitacre
and thereby reduce your risk of dislodging the needle. 3 mL non Luerlok syringesare stocked in the epidural carts.
Other approaches to a CSE technique include the ESPOCAN combined spinal
epidural anesthesia set, equipped with an 18G Touhy and a 27 G spinal needle, and
the individually wrapped 27G Whitacre, which passes with ease through the 18G
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Touhy in the Braun kit. Also, a 25G Whitacre can pass through an 18G Touhy, but
you may detect some resistance.
After the spinal solution is administered, the patients feet should start to feel
warm and contractions should begin to feel less painful within a few minutes.
Patients might become hypotensive from the rapid and profound pain reliefassociated with CSE placement, so be ready to treat with ephedrine. Also, fetalbradycardia associated with the opioid in the CSE solution is not uncommon, and
may also be treated with ephedrine, fluids, oxygen by face mask, and by placing thepatient in different positions (the nurse is very helpful with these maneuvers).
Once the CSE solution has been administered, withdraw the 25 G (or 27 G) needle,
while keeping the Touhy needle in place, and quickly thread the epidural catheter.
Do not dose the epidural catheter. Rather, start the epidural infusion at the routinesettings. Sufficient epidural solution should accumulate in the epidural space by the
time the CSE solution wears off. From time to time, it is helpful to ask the patient to
press the PCEA button within 30 minutes after the procedure and, again, 30 minuteslater to ensure that enough epidural solution has accumulated before the CSE wears
off.
Warn the patient that she might expect pruritus, which is usually selflimited.
CESAREAN DELIVERY WITH IN SITUEPIDURAL
When a C/S is called on a patient with an epidural in place, first confirm that the
epidural is working. Assess the quality and level of the block with the white plastic
swords that are stocked in the top drawer of our epidural cart. Feel the patients legsto assess whether they are both warm (from localanesthetic induced vasodilation).
Ask the patient whether she has been comfortable, and ask her to roll slightly to theside while you assess whether the catheter is still in place and still at the site whereit was originally taped (refer to the labor anesthetic record for this information).
Withdraw the following medications from the Pyxis: 2 vials of 2% lidocaine with
epinephrine (also available in the epidural carts), fentanyl 100 mcg (50 mcg per mL
concentration), duramorph 5 mg (0.5 mg per mL concentration), midazalam 2 mg,three 10 unit vials of oxytocin, ondansetron, and ephedrine 50 mg and
phenyephrine 10 mg (if you no longer have the pressors that were drawn duringepidural placement for that patient). If theres any reason to suspect uterine atony
(for a patient who has had a prolonged induction, a patient with suspected fetal
macrosomia, or a multiplegestation parturient, for example), pull methergine +/hemabate from the icebox in the stock room. The nurses can pull Cytotec
(Misoprostol) from their Pyxis (we do not have access to it). Please be familiar with
dosing regimens, indications and contraindications of each of these drugs.
In patients room, ensure that Reglan 10 mg IV, Bicitra 30 mL PO, and Ancef have
been administered and that the patient has a working IV for fluid administration.
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Note that some obstetricians hold off on administration of Ancef until after the baby
is delivered; the nurse is aware of individual obstetrician preferences.
Disconnect the pump infusion and discard the remaining solution. Then, for non
emergent cases, slowly dose the catheter with 2% lidocaine with epi and
bicarbonate (8.4% solution) in a ratio of 9 mL of lidocaine to 1 mL of thebicarbonate. The bicarbonate serves to raise the pH of the local anesthetic closer toits pKa and hasten onset. Depending on the patients block prior to dosing, you may
need up to 20 mL of the lidocaine with epi/bicarbonate solution to achieve a T4block (block at the nipple line). Give this solution in 35 mL increments with
negative aspiration between each dose and with frequent blood pressure readings.
Note that patients who have had the higher PCEA infusion rate of 12 mL/hr, patients
who have had a documented wet tap with an 18 G or 17 G needle, and those who have
received a CSE may require significantly less 2% lidocaine with epi and bicarb.
For emergent cases, test the catheter in the usual fashion, ruling out intravascular
and intrathecal migration, and dose with 20 mL of 3% 2chloroprocaine withbicarbonate (2 mL bicarbonate per 20 mL of chloroprocaine).
If the epidural block is equivocal, it is prudent not to dose more than 10 mLs of 2%
lidocaine with epi and bicarb (as always, in divided doses) prior to consideringother anesthetic alternatives such as a spinal for the C/S. 10 mL of 2% lidocaine is
more than sufficient to confirm that an epidural is or is not working, as the patient
should get a clear level and dense motor block with that amount. If more than 10 mLof the 2% lidocaine is administered in an epidural that is equivocal, you risk a high
spinal if the decision is made to abandon that epidural and convert to a spinal.
Have the patients husband or significant other wait in the labor suite (OR clothesare stocked in each room) or outside the OR, where OR pants, shirt, hat, and maskare available, until the patient is prepped and draped and checked for an adequate
anesthetic level.
In the OR, place the patient in left uterine displacement (LUD) and administer
oxygen by nasal canula or face mask.
Administer fentanyl 100 mcg per epidural once it has been confirmed that the
epidural quality and level are adequate. We routinely administer Duramorph
(preservativefree morphine) at a dose of 33.5 mg per epidural for postoperativepain relief.
From time to time, the epidural blocks unexpectedly provides inadequate
anesthesia/analgesia during a C/S, and the patient requires IV analgesic adjuvants
such as ketamine, fentanyl or, occasionally, propofol, per your staffs preference. Ifyou withdraw ketamine from the Pyxis, please ensure that it is the 10 mg/mL
concentration, as another, higher concentration is also available. Also, ensure that
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the patients pain is not due to failure to redose the epidural at the appropriate
interval.
Once the baby is delivered, start your oxytocin infusion. Premade bags of 20 units
pitocin in D5LR are available. Alternatively and more often, we place 30 units in 500
mL of LR. Keep the oxytocin infusion open initially; then reassess uterine tonewithin a minute or two and turn down infusion if tone is good. When you start theinfusion, inform the patient that she might feel flushed or lightheaded and that she
might develop a headache. Please be familiar with side effects and adverse effects ofoxytocin.
Document all doses of local anesthetic administered, in both the labor room and in
the OR, as well as vital signs during dosing. Document time of fentanyl and
duramorph administration, in addition to your routine careful documentation of allintraoperative events. We currently record intraoperative events on the labor
epidural document when we transfer to the OR rather than change to a separate OR
record. Indicate on the record the transfer to OR, time, and indication for C/S.
Postoperative orders are to be filled out for each patient who receives duramorph.
After an operative delivery, you are responsible for setting up the OR for the next
possible emergency. Ensure that clean equipment, including breathing circuit, nasal
canula, ETTs, masks, EKG leads, pulse oximeter, blood pressure cuff and cable, and
suction are readily available. Dispose of all used syringes, and waste all unusednarcotics.
Accompany the patient back to the room and document a final set of vital signs and
the end time.
TOPPING OFF LABOR EPIDURALS
If you get called for inadequate analgesia in a patient with a labor epidural, ask the
patient where exactly she hurts and whether her block was adequate earlier in the
course of her labor; check the sensory dermatome level with the white plasticsword; evaluate whether the patient has a motor block; feel whether both legs are
equally warm; check the labor anesthetic record for previous dose, time and result
of last top off and for whether the epidural was a difficult placement; and turn thepatient slightly to her side to assess whether the catheter is still in place and still at
the original insertion site (see anesthetic record to see where catheter was taped atthe skin).
Check the infusion pump, tubing, and bag of bupivacaine solution to rule out
malfunctions, leaks, or empty bags.
Determine the position of the fetus, the station, and the latest cervical exam from
the nurse. This may influence the drug you choose to administer.
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Several top off regimens are appropriate, depending on nature of the patients
pain. For example, if the patient has a dense motor block but a low dermatomal
sensory level, you might consider administering a relatively large volume of a lowconcentration local anesthetic such as 1/8 % bupivacaine or 1% lidocaine or a bolus
from the 0.1% bupivacaine epidural pump solution. Alternatively, if the patient hasa weak or equivocal block and is in great discomfort, a few mLs of 2% lidocaine or % bupivacaine is appropriate. Fentanyl 100 mcg per epidural and/or a few mLs of a
high concentration local anesthetic such as % bupivacaine or 2% lidocaine isoften helpful when delivery is imminent and the patient is complaining of perineal
pain. Similarly, a high concentration local anesthetic and fentanyl per epidural are
useful prior to vacuum or forceps delivery and for manual extraction of the placentaand laceration repairs.
Record the sensory level both before and after your intervention, as well as vital
signs (including fetal heart tones).
Be sure that you have ephedrine readily available as well as a working IV prior to
any top offs. Also, stay in constant communication with the patient during top offs inorder to evaluate CNS changes that may result from an unanticipated bolus of local
anesthetic in the intravascular or intrathecal space. Be aware that catheters canmigrate into subarachnoid and intravascular locations; it is essential also to
administer top offs in divided doses with frequent negative aspirations.
CATHETER PULLS
If you have the opportunity, it is good practice to pull the epidural catheter
yourself, documenting that the tip is in tact. If resistance is met, it is often helpful to
ask the patient to flex her back or assume the position that she was in duringepidural placement.
After the catheter is pulled, you can close out the chart, documenting the delivery
time, Apgars, etc.
Empty the infusion bag and document waste in mLs on the anesthetic record.
If a patient has any complications such as atony, concern for retained products, or
excessive bleeding during delivery, it is prudent to leave the catheter in situ until
concerns have been resolved and the nurse is ready to transfer the patient to thepostpartum unit.
SUBARACHNOID BLOCKSWhen a spinal anesthetic is indicated for a Cesarean delivery, ensure that the
patient has a working IV and has received Reglan 10 mg, Bicitra 30 mL PO, andAncef (unless the obstetrician prefers to hold antibiotics until after delivery).
Consider an IV crystalloid preload or coload. According to the ASA Obstetric
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Anesthesia guidelines: Intravenous fluid preloading may be used to reduce the
frequency of maternal hypotension after spinal anesthesia for Cesarean delivery;although fluid preloading reduces the frequency of maternal hypotension, initiation
of spinal anesthesia should not be delayed to administer a fixed volume ofintravenous fluid. The timing of your fluid administration is controversial; defer to
your staff.Ensure that the OR is properly equipped with suction, a breathing circuit, a face
mask, nasal cannula, working laryngoscope and blade, ETTs of varying sizes, emesis
basin, emergency medications, succinylcholine, an induction agent, etc.
Withdraw fentanyl, duramorph, versed, pitocin, ephedrine and phenylephrine
(unless a bag with phenylephrine 100 mcg/mL has been prepared already) from thePyxis, as in the case of an epidural for C/S.
Open and prepare the spinal tray (located in the neuraxial block cart in each OR)
equipped with a 25 G pencilpoint needle. Note that we have more than one spinaltray, so review the box contents before opening.
In a sterile fashion, draw up 1.42.0 mLs (depending on patients height, weight,
and number of prior Cesarean deliveries, as well as on your staffs preference; weoften use 1.6 mLs) of the 0.75% bupivacaine into the sterile syringe. Use the filterstraw that is provided in the kits to draw up your local anesthetic, as glass particles
from the glass bupivacaine vial can otherwise contaminate your anesthetic solution.
Have an assistant draw up fentanyl (1020 mcg, depending on your staffs
preference) and duramorph (100200 mcg, depending on staffs clinical judgment)
in a TB syringe and insert it into your bupivacaine solution. Alternatively, drop a TBsyringe onto your sterile field and withdraw the appropriate amount of each opioid
while an assistant holds the vials for you. Push air bubbles out your spinal mix prior
to starting the procedure.
Occasionally we also add epinephrine to our local anesthetic/opioid mix for
subarachnoid blocks in order to prolong the effect and, possibly, for enhancedanalgesia. The epinephrine is available in the kits, and you can do an epi wash
before drawing up your 0.75% bupivacaine by showering the inside of your syringe
with epi. Alternatively, consider adding 100200 mcg of epinephrine to your localanesthetic/opioid solution. Note that some practitioners prefer to avoid epinephrine
in the setting of preeclampsia or hypertension. Also, please be careful to distinguishbetween the epinephrine and bupivacaine glass vials, both of which are supplied in
the kits. When drawing up your medications, look at the vial, read the expiration
date and concentration of the bupivacaine, and keep the smaller epinephrine glassvial a safe distance away in order to minimize medication errors.
The patient may be seated or in the lateral position during placement of asubarachnoid block. All monitors should be in place and your pressors should be
immediately available (some may prefer to pretreat with IV or IM ephedrine).
After the 25 G pencil point needle is advanced through the introducer until a dural
pop is detected, withdraw the stylette and watch for CSF backflow. Attach the
syringe with the spinal solution carefully to the 25 G and hold steadily in place; it ishelpful to visualize a small whirl of CSF in the syringe prior to injecting the solution
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by gently withdrawing the syringe. Warn the patient that her legs will start feeling
heavy and warm as the solution is administered into the intrathecal space.
After administering the solution, have the patient immediately lie down (if she had
been seated) or roll over on her back (if she had been in the lateral position) andplace the patient in left uterine displacement. Administer oxygen by nasal cannula
or face mask, take frequent blood pressure readings, and maintain constantcommunication with the patient for several minutes as the spinal sets up. Ask thatthe patient alert you if she begins to feel nauseated, lightheaded, confused or dizzy,
as these are early signs of hypotension or a high block. Be prepared to treat withephedrine or phenylephrine and IV hydration. Be familiar with the OR set up,
particularly with where emergency equipment and drugs are located.
If patients get anxious and feel that they cannot breathe, for example, reassurance
and continuous communication is often helpful, as is having the significant other
join you in the OR. Versed in 12 mg IV also helps alleviate the anxiety, althoughsome practitioners prefer to hold off until after delivery.
Assess the level of your block with the white plastic swords. Ask the patient to
squeeze your hands is an effective way to rule out a high block, as is listening for astrong, unchanged voice.
Alternative spinal kits and needles are available for difficult cases, such as super
morbidly obese parturients. Please defer to your staff.
For repeat Cesarean deliveries (a third or fourth C/S), patients who are super
morbidly obese, patients who have had multiple abdominal procedures and have
suspected adhesions, patients who desire tubal ligation after Cesarean delivery,patients with previas, accretas, or other uterine pathology, etc. a combined spinal
epidural may prove an appropriate anesthetic technique. The CSE for a surgical
procedure is performed in the same manner as a CSE for laboring patients, but the0.75% bupivaine/opioid solution described in this section (+/ epinephrine) is
administered in lieu of the lighter local anesthetic solution used during labor. Whenperforming a CSE for surgical procedures, thread the catheter quickly after
administration of the anesthetic solution and place patient supine with LUD as
swiftly as possible.
COMPLICATIONS OF NEURAXIAL BLOCKS
Hypotension:
Hypotension is a common side effect of administration of local anesthetic in the
epidural or subarachnoid space.
Confirm LUD, evaluate the patient for symptoms (n/v, dizziness, lightheadedness,etc.), and assess the fetal heart tracings.
Open the IV fluids and administer ephedrine if the patient is symptomatic, the fetus
is in distress, or if there is a greater than 20% drop in SBP. Consider oxygen by mask
or positional maneuvers. Get help, if necessary.
Check the patients anesthetic level and rule out inadvertent spinal, accidental
excess local anesthetic dose, etc.
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Wet Tap:
Remain calm and reassure patient. Immediately take a course of action: either
thread the catheter intrathecally or remove the Tuohy needle and attempt epidural
placement at another level.
If you opt to thread the epidural catheter into the intrathecal space, 25 cm
(maximum) should suffice. Confirm backflow of CSF, and dose the intrathecalcatheter for a laboring patient per your staffs preference. You might start with 1 mL
of 0.25% bupivacaine with fentanyl 15 mcg (as we do with CSEs for laboring
patients), followed by a continuous infusion of 1 mL of 0.1% bupivacaine with 2mcg/mL of fentanyl per hour. Adjust you dose as necessary, but be sure to opt for
continuous infusion on the pump settings and to disable the patientcontrolleddosing option. Tell the patient that her catheter is in the CSF space and that she
might be at risk of a headache, explaining that wet tap with headache is a not
unusual complication of epidural placement. Label the catheter as intrathecal,advise the nurse and all staff, and write intrathecal catheter on the board next to
the patients name.
If you opt to remove the Touhy and attempt epidural placement at another level,advise the patient that she might develop a headache. Also, be aware that dosing the
epidural in the setting of a prior frank wet tap might require dosing adjustments.Dose the epidural prudently and with frequent assessements and blood pressure
measurements; reassess the patient frequently during the course of her labor.Document that the patient had a wet tap on both the labor record and in our
logbook in the stock room. Also, pass on the word to staff and team members who
take over after you. Follow up on these patients for 35 days postpartum, assessingfor any signs of postdural puncture headache (PDPH).
On occasion it takes multiple attempts to locate the epidural space, placing the
patient at risk for a dural tear even in the absence of a frank wet tap. Please inform
the patient and team members who assume care once your shift is over that thepatient may be at risk for a headache. Communication is essential in this scenario, as
otherwise the patient may go untreated for a PDPH.
PDPH:
Whether the patient is in the hospital or at home, obtain and review the chart.
Evaluate needle size, difficulty of placement, number of attempts, and whether there
was a frank wet tap. The nursing supervisor is available 24 hours/day in the
hospital and can obtain the anesthetic record from Medical Records at any hour.
Evaluate the nature of the headache. When did it start? Is it positional? Where does
it hurt? Is it totally relieved when lying down? Does patient have tinnitus, visualchanges or nuchal rigidity? Does she recall whether the epidural placement was
difficult or was she warned that she might develop a headache? Does she have a
history of headaches, and is this headache similar to her usual headache? Has sheresumed her normal caffeine intake and has she been eating? Does she have a
history of high blood pressure, was her pregnancy complicated by high bloodpressure or preeclampsia, and what is her blood pressure currently? Is she febrile?
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Examine the spinal/epidural injection site and assess patients motor strength.
Assess also the patients hydration status.
Conservative management for a PDPH is a good option for 24 hours. Consider bed
rest, with the head of the bed flat; hydration; scheduled motrin or fioricet;antiemetics, if necessary; have the patient resume her caffeine intake and avoid
alcohol; explain the probable etiology of the headache and the epidural blood patchtreatment option.
A blood patch can be considered if the patient declines conservative treatment, is
to be discharged that day, has documented evidence of a frank wet tap, or fails
conservative treatment. Explain all the risks and benefits of an epidural blood patch
and have patient sign a consent form prior to the procedure. An anesthetic recordshould be filled out for a blood patch. A fellow or staff member will either perform
the blood patch or assist you.
After a blood patch, instruct the patient to avoid straining, rapid bending, bearing
down, or lifting heavy objects for several days. Also ask her to refrain from alcohol
intake. She can continue taking motrin or fioricet (taper the latter in the usual
fashion).Request that the patient return to the ER or for an anesthesia consult if the
headache recurs, a fever or stiff neck develops, she develops numbness or weakness
in her lower extremities or bowel/bladder dysfunction, if increased redness or
tenderness develops at the injection site, or if she has any questions or concernsabout her anesthetic care.
Advise the patient that in a small percentage of the cases, a second epidural blood
patch may be required. Give her statistics regarding the success rate of a first blood
patch, the success rate of a second, the timeframe for resolution of the headache if itrecurs, etc.
Record that a blood patch was performed on that patient in the log in the stock
room.
Asymmetic Sensory Block:
A unilateral block is a common complication of epidural procedures. It is often
associated with a catheter being threaded (or migrating) too deep into the epiduralspace (literature suggests that threading the epidural catheter 35 cm is optimal) or
with having the patient lie on one side for too long.
To troubleshoot, roll the patient on her side and ensure that the catheter is at the
proper depth at the skin; if it has migrated inward, pull it back to the site where it
was originally taped at skin and, after repositioning the patient on the side without
the block, either give a manual bolus of a local anesthetic solution or ask that thepatient press her PCEA button. If the catheter is still where it was originally taped,
roll the patient on the side that has diminished analgesia, withdraw the catheter 12cm and bolus as above. Remember to aspirate prior to administering any bolus.
Patchy Block:
Assess where the patient is feeling discomfort. Does she have a window of pain?
Is she experiencing perineal pain immediately prior to delivery?
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Rule out a subdural block; to do this, you must be familiar with the manifestations
of a subdural block. If you feel certain that the patient is experiencing a subdural
block, consider immediately replacing the catheter.
If the patient is experiencing perineal pain, consider fentanyl 100 mcg per epidural
or a few mLs of a dense local anesthetic solution, as described in the troubleshooting
section.If the epidural is working properly and the patient has a window of pain, consider
a bolus of a dense local anesthetic solution with the patient lying with the unblockedsegment down. Have a low threshold for replacing these catheters, as it is often
difficult to remedy a window.
Fetal Bradycardia:
Ensure that the nurse is present and has placed the patient on her side to avoid
compression of the blood vessels.
Consider oxygen by mask.
Evaluate the patient for symptoms of hypotension; take a blood pressure reading.
If the patient is symptomatic or hypotensive, open the IV fluids and administer
ephedrine. Administering ephedrine is often helpful also in the absence of overt
hypotension.
Notify your team if the bradycardia continues and if there is concern for imminent
C/S.
Have 20 mL of 3% 2chloroprocaine with 2 mL of bicarbonate drawn up for
immediate dosing of the epidural if proceeding to the OR emergently is imminent.
Intravascular Injection:
When testing a catheter, remember that every dose is considered a test dose. Use
3 mL increments of local anesthetic with frequent negative aspirations and frequentblood pressure readings.
To assess for intravascular injections, ask if the patient has ringing in the ears,
dizziness, circumoral numbness or a metallic taste on the tongue, restlessness, or
suddenonset anxiety. Watch for tachycardia (if an epinephrinecontaining localanesthetic was used) and for seizure (if a large amount of high concentration local
anesthetic was dosed at once). Also, take a small syringe and draw back for blood
when evaluating a suspicious scenario. Hold the syringe below the level of thepatient as you gently and protractedly draw back.
Of note, remember that we routinely administer 100 mg of lidocaine intravenously
in the OR without noting any of these signs and symptoms described above; several
mLs of the local anesthetic solution may be necessary for the patient to detect anysensory changes. Also, be reassured that we use low concentrations of local
anesthetic in small, incremental doses with frequent aspirations in order to
minimize complications of intravascular injections. Lastly, the soft, wirereinforcedcatheters in common use today have a lower incidence of intravascular cannulation.
In the event of a known intravascular injection of doses greater than a test dose or
if the patient is symptomatic, stop injecting, get help STAT, prepare for
administering oxygen and protecting/supporting the airway, and prepare
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emergency drugs, including lipid. Have a low threshold for transfer to the OR, if the
problem persists.
OBSTETRIC ANESTHESIA CURRICULUM: LEVEL 1
Note: For specifics on fulfilling the 6 core competency requirements, please refer to theObstetric Anesthesia guidelines posted on the Tulane departmental Website. The
following provides an abbreviated version of expectations for your manual skills
development and your core knowledge acquisition over the course of your rotations in
Obstetric Anesthesia. The curricula below are modified from the Society for Obstetric
Anesthesia and Perinatology (SOAP), and are not intended to be exhaustive.
Manual Skills Development:
Residents are expected to learn and develop proficiency in the following skills
during routine cases: 1) epidural catheter placement with a success rate of 70% bythe end of the month; minimal number of wet taps 2) subarachnoid block placement
with a success rate of 7080%
Core Knowledge Acquisition:
A) Maternal physiology prior to labor and deliverya. Cardiovascular system: cardiac output, stroke volume, heart rate,
systemic vascular resistance, blood pressure, and blood volume
b. Describe the effects of supine position on blood pressure and uterineblood flow
c. Pulmonary, respiratory and airway: functional residual capacity, tidalvolume, respiratory rate, minute ventilation, alveolar ventilation,
work of breathing, airway resistance, chest wall compliance, arterial
blood gases, ventilation/perfusion matching, and Mallampati (bothover the course of pregnancy and during labor)
d. Gastrointestinal: gastric motility, gastric emptying, lower esophagealsphincter tone, gastric pH, risk of aspiration pneumonitis
e. Hematologic: hematocrit, blood volume, platelets, white blood cells,coagulation factors, fibrinogen
f. Renal: BUN, Cr, glomerular filtration rate, renal blood flowg. Endocrine and metabolism: progesterone, estrogen, prolactin,
aldosterone, angiotensin, rennin, cortisol, prostacyclin, thromboxane,insulin and glucose, etc.
h. Musculoskeletal: back pain, sciatica, carpel tunnel syndrome, lordosisi. Central nervous system: pain tolerance, anesthetic requirements for
both general and regional anesthesia
B) Fetal and placental physiologya. Embryogenesisb. Placental development and structurec. Placental gas exchange, nutrient transport, drug transferd. Fetal circulation
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e. Fetal evaluation: Intrauterine growth restriction (IUGR), nonstresstest (NST), biophysical profile (BPP), fetal heart rate (FHR), fetal bloodgas values, etc.
C) Neonatal physiologya. APGARb. Physiologic adaptations to extrauterine life, including circulatory andrespiratory changesc. Resuscitation of the newborn: what is the role of the anesthesiologist?
D) Local anestheticsa. General principles of LA pharmacologyb. Criteria for selecting specific LAsc. Describe effects on maternal circulation, uterine tone, uterine blood
flow, and FHR
d. Effect of vasoconstrictorse. Effect of sodium bicarbonate on onset and durationf. Signs and symptoms of systemic toxicityg. Neurotoxic effectsE) Agents affecting uterine tonea. Agents that affect uterine tone: volatile agents, ketamine,
nitroglycerineb. Tocolytics: Ethanol, Mg, calcium channel blockers, etc.c. Uterotonics: Pitocin, Cytotec, Methergine, Hemabate.
F) Opioids:a. Opioid agonists for neuraxial blockadeb. Treatment of opioid side effectsc. Mixed agonistantagonistsd. Effects on the fetus
G) Drug interactionsa. What are the effects of vasoactive agents on the onset, intensity, and
duration of sensory and motor effects of LAs?
b. What are the effects of opioids on the onset, intensity, and duration ofsensory and motor effects of LAs?
c. What is the effect of sodium bicarbonate on the onset, intensity, andduration of LAs?
d. How does magnesium affect neuromuscular blocking drugs?H) Management of labor
a. Describe the first (active and latent phases), second and third stagesof labor
b. Describe the effects of uterine contractions on placental exchange andfetal oxygenation
c. Describe the anatomy of the epidural spaced. What are the clinical manifestations of uterine hypertonus and
hyperstimulation
e. Does epidural analgesia affect labor?f. How does labor affect maternal hydration, ventilation, and
hemodynamics?
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I) Regional anesthetic techniques for the obstetric patienta. Describe techniques available for routine labor and vaginal delivery,
vacuum or forceps delivery, manual extraction of the placenta, uterine
inversion, nonurgent and emergent Cesarean delivery, dilation andcurettage (D&C), tubal ligation, and cervical cerclage
b. Describe neurologic pathways that convey pain during the first andsecond stages of laborc. List all regional anesthetic techniques that can produce effective
analgesia in the first and second stages of labor
d. List absolute and relative contraindications of regional anesthesiae. Describe the hemodynamic effects of epidurals and subarachnoid
blocksf. List complications of regional anesthesia, including PDPH, backache,
nerve palsy, meningitis, abscess, and hematoma
J) General anesthetics for obstetricsa. What are some of the concerns about administering general
anesthesia to a parturient, both early in pregnancy and at term?b. List indications for general endotracheal anesthesiac. What are the ventilatory requirements for parturients?d. Describe how drugs used in the induction and maintenance of general
anesthesia affect uterine tone, fetal perfusion, and the neonate
e. Describe the steps of the difficult airway algorithmK) Resuscitation
a. Describe clinical factors (both maternal and fetal) that are predictiveof a need for neonatal resuscitation
b. Describe ideal management of maternal resuscitationL) Complications of anesthesia during pregnancy
a. Aspiration pneumonitisb. Failed intubationc. Complications during emergenced. PDPHe. Common neurologic complications
M)Anesthetic management of nonobstetric surgery during pregnancya. Describe advantages and disadvantages of performing elective
operations during the first, second and third trimesters of pregnancy
b. When is fetal heart monitoring (FHM) indicated?c. Do our anesthetic agents affect the fetus? Which ones? How?d. Discuss the effects of maternal hypotension, hyperventilation,
hypoventilation, and blood transfusion on fetal well beingN) Ethical Issues
a. Discuss the potential for maternalfetal conflicts of interestb. Discuss the current gestational ageweight limits for fetal viabilityc. Discuss informed consent issuesd. Demonstrate an understanding of divergent religious points of view
O) Crisis aversion
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a. Diabetes, with emphasis on the criteria for diagnosis, indications fortherapy, effect of pregnancy on the disease process, fetal effects of thedisease, and the effects of treatment on both mother and fetus
b. Thyroid disease, with emphasis on diagnosis and treatment of bothhypothyroidism and hyperthyroidism
H) Substance abusea. Identify risks and complicationsb. Recommend postoperative pain control strategiesc. Develop a plan for complications of withdrawal
I) Immunologic diseaseJ) Neurologic disorders
a. Multiple sclerosisb. Spinal cord injuryc. Myasthenia gravisd. Seizure disorders
K) Respiratory diseasea. Asthma, including the pathophysiology, the effects of pregnancy onasthma, and asthmas effects on pregnancyb. ARDS
L) Cardiovascular diseasea. Congenital heart diseaseb. Ischemic heart diseasec. Valvular heart diseased. Peripartum cardiomyopathy
M)Hematologic and thromboembolic diseasea. Anemiasb. Thalassemiasc. Sickle cell diseased. Thrombocytopeniase. Platelet and bleeding disordersf. Anticoagulation medications
N) Morbid ObesityO) Malignant HyperthermiaP) Renal diseaseQ) Liver diseaseR) Musculoskeletal disorders
a. Scoliosisb. Rheumatoid arthritisc. Spina bifidad. Prior back surgery
OBSTETRIC ANESTHESIA CURRICULM: LEVEL 3
A) Act independently as a consultant, formulating an anesthetic plan for highrisk parturients
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B) Develop critical evaluation skillsC) Develop management and leadership skills
a. Demonstrate independenceb. Develop communications skillsc. Demonstrate leadershipd. Supervise junior residentse. Teach junior residents and participate in management tasksf. Introduction to clinical researchg. Bedside teaching