Women's Anaesthesia

I About The Programme
II Assessment and Evaluation
III Target Audience and Eligibility Requirements
IV Other Information

I About The Programme

Name of Programme

Obstetric Anaesthesia Fellowship

Overview

The Department of Women’s Anaesthesia in KK Women’s and Children’s Hospital in Singapore offers advanced clinical training, teaching and research in a setting that delivers 12,000 women per year. This is a tertiary referral center that provides a full range of obstetric-related care. Commonly encountered pregnancy-related problems include pre-eclampsia, diabetes, prematurity, morbid obesity and multiple gestation. Complex patients are approached by an interdisciplinary team that includes perinatologists, neonatologists, anaesthesiologists and other medical and surgical consultants as needed.

The department is accredited for training by the Australian and New Zealand College of Anaesthetists and hosts rotating Registrars and Medical Officers training in Obstetric Anaesthesia and Research.

For more information on the Department of Women’s Anaesthesia, click here.

Aim of Programme

This Obstetric Anaesthesia Fellowship programme is designed to provide a comprehensive experience designed to develop the professional behaviours, medical knowledge and clinical skills required to provide competent, safe and effective perioperative anaesthesia care for pregnant women. The trainees will also experience the knowledge and clinical skills in perioperative anaesthesia management for complex obstetric cases.

Duration of Programme

6-12 months

Number of Training Places

1 trainee at any one time

Learning Outcomes

Knowledge

To acquire basic science knowledge of physiology and pharmacology in the clinical management of obstetric anaesthesia.
To have a good understanding of the normal labour process and how the course may be affected by unexpected complications and conditions.
To acquire and apply fundamental knowledge of obstetric anaesthesia and perioperative care.
To have a good understanding of the mother’s pre-existing medical condition and its impact on perinatal care.
To have a good understanding of how these conditions may complicate the labour process and how the course may be affected by unexpected complications and conditions.

Skills

To refine technical skills and judgment required for safe and effective regional anaesthesia in complicated obstetrics.
To be able to evaluate an Obstetric patient with a more complicated problem, be it medical or social, be it an elective or emergency case.
To formulate an anaesthetic plan and able to justify the reasons with a faculty.
To be able to appreciate the need for different levels of monitoring and intra-operative care.

Attitude

To be able to learn appropriate professional, communication and system-based practice while working as an obstetric anesthesia team member.
To participate actively in departmental teaching programs, audits, critical incidents reporting, seminars and conferences.
To develop teaching skills in the education of medical students, residents as well as other inter-professionals.
To participate actively in the clinical and educational research in the department.
To understand the administrative processes in the care of an obstetric patient.

Content Areas

This curriculum focuses on acquisition of the fundamental competencies required for routine and complicated anaesthesia care of women during pregnancy and delivery. Trainees are expected to develop proficiency in routine and complex obstetric anaesthesia care, becoming progressively self-reliant while training under the direct supervision of the obstetric anaesthesia faculty.

Training Methods

Trainees will have clinical, teaching and research responsibilities:

Clinical Responsibilities
The programme begins with a one-month intensive upgrade of clinical skills (including night calls). Thereafter, the trainee will spend 50% of the time providing clinical care. When assigned to the obstetric anaesthesia service, the trainee will both provide direct clinical care, as well as instruct and guide residents assigned to the obstetric anaesthesia service. The women’s division is also responsible for anaesthesia in gynaecology, oncology and urology patients. Other clinical responsibilities will include assignment to the general operating suites one day per week.

Teaching
All trainees are involved in the teaching mission within the department by participating in the Mortality and Morbidity conferences and weekly journal club. Clinical teaching includes instruction in the techniques of labour analgesia and operative anaesthesia as well as the more subtle understanding of how to manage the provision of anaesthetic services in a busy labour ward. Didactic teaching includes presentation at departmental journal club and organising and participating in weekly resident and student discussions of obstetric anaesthesia topics.

Research
Trainees are expected to actively participate in ongoing projects. In addition, trainees will design and carry out their own research projects with the support and guidance of members of the section of obstetric anaesthesia. Trainees are encouraged to attend local and international conferences to present abstracts and lectures; funds made available to achieve this.

II Assessment and Evaluation

Aims of Assessment

Trainees are required to continually demonstrate the following six competencies throughout the programme:

(A) Patient Care

Pre-Operative Assessment

Undertake satisfactory preoperative assessment of the pregnant patient
Obtain informed consent for regional or general anesthesia for elective obstetric procedures
Demonstrates the ability to clearly explain and prepare an obstetric patient for surgery
Explain appropriate fasting time
Explain the rationale and prescribe appropriate premedications to minimise the consequences of pulmonary aspiration

Peri-Operative Care

Adequate preparation for the conduct of a safe regional or general anaesthetic, including machine and equipment checks and availability of emergency/resuscitative drugs to manage an obstetric patient
Demonstrates the use of techniques to avoid aorto-caval compression
Demonstrates the ability to provide spinal anaesthesia for caesarean section under direct supervision
Demonstrates the ability to provide general anaesthesia for caesarean section under direct supervision
Demonstrates the ability to provide anaesthetic care for parturient undergoing non-obstetric surgery under direct supervision
Observe a combined spinal anaesthetic for labour or instrumental delivery
Practical experience in central neuraxial blocks on the epidural part-task trainer
Demonstrates satisfactory assessment of pregnant woman presenting for anaesthesia/analgesia including those with concurrent disease
Demonstrates ability to communicate a balanced view of the advantages, disadvantages, risks and benefits of various forms of analgesia and anaesthesia appropriate to individual patients
Demonstrates the ability to choose the most appropriate regional technique for an operative delivery and justify the decision
Formulate an appropriate anaesthetic/analgesic plan after discussion with supervising faculty
Explore and address patients’ and relatives’ concerns

Specific Anaesthetic Management Skills

Optimise maternal safety and foetal well-being
Demonstrates the ability to provide intra-uterine resuscitation for the “at risk” foetus Demonstrates the appropriate use of CSE, sub-arachnoid, and epidural analgesia for labour or instrumental delivery
Demonstrates the ability to convert epidural analgesia to epidural anaesthesia for surgical intervention
Demonstrates the ability to manage complications of regional block including:
- Inadequate/failed block
- Hypotension
- High/total spinal block
- Systemic local anesthetic toxicity
- Inadvertent dural puncture
Demonstrate competency in airway management in the parturient
Anticipate potential problems and develop contingency plan
Demonstrate flexibility when the expected peripartum course changes in some patients
Provide assistance for neonatal resuscitation
Demonstrates safe and effective management of post-delivery pain relief

(B) Medical Knowledge

A good foundation in basic sciences is essential in understanding the practice of obstetric anaesthesia. The trainee must be familiar with the anatomy, physiology and pharmacology related to pregnancy and labour.

Anatomy

Anatomy of the vertebrae, especially the lumbosacral vertebrae
Anatomy of the spinal meninges, subarachnoid and extradural space; and the contents of the extradural space
Anatomy of the CSF system
Understand the anatomical course of spinal nerves
Applied knowledge of spinal dermatomes
Explain the anatomical effects of the gravid uterus, aortocaval compression and measures that can be taken to avoid it

Physiology

Physiological changes associated with pregnancy
Materno-foetal, foetal and neonatal circulation
Functions of the placenta
Placental exchange and transfer of drugs
Pain pathways relevant to the stages of obstetric labour and delivery
Physiological changes of the foetus at birth
Physiology of lactation

Pharmacology

Pharmacology of local anesthetic agents, including:
- Physicochemical properties
- Mechanism of action
- Pharmacokinetics of commonly used agents
- Concept of safe clinical and maximum clinical doses
- Adverse effects
- Treatment of local anesthetic toxicity
Adjuvant drugs used in central neuraxial blockade
Pharmacology of uterotonic drugs
Transfer of drugs across placenta and breast milk, and its implications

Clinical Practice of Obstetric Anaesthesia

Understand common obstetric indications for anaesthetic intervention on the delivery suite
Basic understanding of common complications arising in pregnancy and their anaesthetic implications
Understand the indications and contraindications for regional anaesthetic techniques
Explains departmental fasting policies
Understanding of maternal and neonatal resuscitation algorithms
Physiology of normal and abnormal pregnancy, including physiology of labour and childbirth
Understand the principles underlying various monitoring modalities for the in-utero assessment of foetal well-being
Recalls/describes how to assess foetal well-being in-utero

Management of Obstetric Conditions and Complications

Discuss the management and anaesthetic implications of common medical conditions in pregnancy:
- Pre-eclampsia and eclampsia
- Gestational diabetes mellitus
- Placenta praevia
- Antepartum haemorrhage
- Multi-foetal gestation
- Preterm labour
- Vaginal birth after caesarean (VBAC) delivery
List the risk factors and describe the management of major obstetric haemorrhage
Explain the thrombo-prophylaxis requirements in pregnancy
Describe the grading of urgency of Caesarean section
Describe the clinical symptoms and management of post-dural puncture headache
Know the indications for an epidural blood patch
Evaluate a patient with a postpartum neuropathy to determine sensory and motor nerve involvement and describe the appropriate steps to take to determine etiology. Be familiar with the common nerve palsies associated with the labor and delivery process, and be able to differentiate these from those potentially associated with regional anaesthesia.
Describe the relationship between epidural block and postpartum backache.
Describe the pathophysiology of pre-eclampsia, outline the preoperative evaluation of a patient with pre-eclampsia and develop an anaesthetic plan that encompasses the particular anaesthetic concerns with these patients.
Know the pharmacokinetics of the commonly used tocolytic agents and management of their detrimental side effects.
Describe the anaesthetic management of a patient for preterm delivery, which includes consideration of maternal and foetal issues.
Describe the anaesthetic management of both vaginal and operative delivery for a patient with multiple gestation that includes a discussion of the management of the potential anaesthetic and obstetrical complications.
Describe the obstetrical and anaesthetic concerns for a patient presenting with a breech presentation. Be familiar with the anaesthetic management of the trapped 'after coming head'.
List the causes of antepartum and postpartum haemorrhage, and the anaesthetic and obstetrical management. Be able to identify patients at risk for obstetrical haemorrhage.
Describe the clinical signs and symptoms of amniotic fluid embolus and be able to describe the features that distinguish this from other causes of embolism.

(C) Practice-Based Learning and Improvement

Identifies gaps in clinical knowledge and takes steps to address these gaps to obtain current information
Learn to better utilize information technology to access on-line medical information pertaining to innovative diagnostic and therapeutic modalities in the area of obstetrical anesthesia
Assimilate into clinical practice new advances upheld by current peer-reviewed literature.

(D) Interpersonal and Communication Skills

Trainees must develop effective communication skills in their interactions with patients, relatives, medical and non-medical staff. These skills include:

Commits to establishing an open and honest rapport with patients and their carers, tailoring language and terminology to their needs
Obtain anaesthetic consent, communicating a balanced view of the risks and benefits of various forms of analgesia and anaesthesia
Commits to encouraging questioning, listening actively and ensuring comprehension by the patient/carers
Speaks in a clear and concise manner
Convey respect for others and display an appropriate degree of confidence
Demonstrate the ability to interact with obstetrician and members of health care teams in a constructive, positive and effective manner.
Verbally present a concise anaesthetic pre-operative evaluation to a senior colleague, emphasising any concerns the resident may have

(E) Professionalism

Undertakes responsibilities with honesty and perseverance
Demonstrate a commitment to ethical principles pertaining to patient care
Maintains full, comprehensible, accurate and contemporaneous written records
Commits to the need to show respect for patient confidentiality
Recognises when the offer/use of a chaperone is appropriate or required
Create well-organised, clear, succinct but thorough and legible, medical record entries.
Understands the need to call for assistance, when problems are encountered in any aspect of patient care
Is able to receive feedback appropriately for the purpose of self-improvement and provides feedback to others when asked
Respects and values the contribution of other healthcare professionals and allied healthcare professionals

(F) Systems-Based Practice

Advocate quality health care, provide sound medical advice and assist patients in dealing with complex health issues
Describe how to access local maternity guidelines and the value of having these guidelines
Incorporate considerations of cost awareness and risk-benefit analysis in parturient without compromising care
Work effectively with other members of the health care delivery team to improve health care and health care system performance

Evaluation Process

Each trainee will be assigned an SMC-appointed supervisor who will facilitate the evaluation of the trainee in the following manner:

3-monthly work-based evaluations by pooled faculty feedback
Assessment will be based on the six core competencies, and other academic pursuits

The supervisor will provide the trainee with confidential feedback at the end of each 3-month duration.

III Target Audience and Eligibility Requirements

Target Audience

Advanced Trainee Grade, (foreign-trained) who has an interest in the subspecialty of Obstetric Anaesthesia

Pre-requisite/Eligibility Requirement(s)

Candidates must meet the Singapore Medical Council’s requirements.

IV Other Information

Course Fees

Course fees will be disclosed upon acceptance.

Funding

Candidates should be self-funded or have funding from external sources/institutions.

Certification

A certificate will be awarded upon completion of the programme.