TRAINING MODULE

in

OBSTETRIC ANAESTHESIA

at

The Royal Berkshire Hospital

Rosie Jones November 2005

Jane Bird Revised 2009
Guy Jackson Revised Sept 2012
Sarah Williams Revised July 2017
Sarah Williams Revised 2019
CONTENTS

Introduction…………………………………………………………………………3
Competence in Obstetric Anaesthesia...........................................................4
Copy of Initial Assessment in Obstetric Anaesthesia document……………. 5
Records of assessments for Initial Assessment of Obstetric Anaesthesia .. 6
Core knowledge………………………………………………………………… 7
Clinical Experience…………………………………………………………… 10
Assessment list for LSCS under general anaesthesia……………………… 12
Assessment form for LSCS under regional anaesthesia…………………… 13
Assessment list for the insertion and management of obstetric epidural…. 14
RCOA basic level training RCOA 2010 workplace based assessments….. 15
Obstetric anaesthesia at the Royal Berkshire Hospital (RBH)

The maternity unit at the RBH covers a large area of Berkshire, from
Lambourne in the West to Bracknell in the East, with nearly 5000 deliveries a
year.

http://www.royalberkshire.nhs.uk/wards-and-services/maternity.htm

Obstetric anaesthesia at the RBH is a busy, enthusiastically run and

rewarding part of the work delivered by the anaesthetic department.

Consultants with a specific interest in Obstetric Anaesthesia and regular

sessions on delivery suite:

Dr Lauren Williams (Current lead for obstetric anaesthetics)

Dr Doug Barker
Dr Guy Jackson
Dr Rosie Jones
Dr Jon Mayer
Dr Ali Reeve
Dr Clare Skinner
Dr Simon Tunstill
Dr Sarah Williams

The anaesthetic department provides dedicated, resident 24/7 anaesthetic

cover to the delivery suite. We have a significant number of CT2 anaesthetists
new to obstetric anaesthesia in our department and provide directly
supervised consultant training in obstetric anaesthesia.

Monday to Friday
 Consultant / senior trainee (ST4+) covering the elective LSCS list (5
days a week)
o 08.00 – 12:30
 Consultant covering delivery suite
o 08.00 – 20.30
 Duty anaesthetist / Trainee (CT2 or ST4/5)
o 08.00 – 20.30
o 20.00 – 08.30
 Anaesthetic clinic Wednesday am
o Consultant 08.00 – 12.30

Weekends, Bank holidays and after 20.30 weekdays

 Duty anaesthetist / Trainee (ST2 or ST4/5)
o 08.00 – 20.30
o 20.00 – 08.30
 Additional cover available if required:
o Senior trainee anaesthetist (ST4/5) resident covering general
surgical and intensive care emergencies
 08.00 – 08:30
 20.00 – 08.00
o Consultant, resident for the labour ward handover at 08:00 and
beyond depending on workload and clinical need in the hospital.
o 08.00 – 08.00 resident and non resident cover
We hold a weekly anaesthetic antenatal clinic to assess women flagged by
the midwives and obstetricans as needing more input. There is also a joint
cardiology and anaesthetic clinic to assess women with potential or actual
cardiac pathology.

We can offer the following clinical and management opportunities that allow
us to offer basic and higher obstetric competency training the CT2 and ST4/5
trainees as appropriate.

Clinical
 Elective LSCS lists
 Sessions on labour ward, ideally covering a junior ST in consultant
morning session
o Teaching opportunity
o Clinical responsibility
 Antenatal anaesthetic clinic
o Wednesday morning (first appointment 8.15)
o Either observing or joining in
 Antenatal joint cardiology / obstetric / anaesthetic clinic
o Tuesday afternoon (3rd of month)

Teaching
o Introduction to anaesthetics for obstetrics session at start of placement
o Practical Obstetric Multi-professional training course (PROMPT)
o In-situ multi-professional simulation training
o Multi-professional breakfast club meeting Tuesdays and Fridays
o Neonatal life support training
o Ad hoc teaching sessions on delivery suite

Management
 Obstetric clinical governance meeting
o 1st Friday of the month 2pm Maternity meeting room
 Obstetric audit meeting
o 1st Friday of the month 1pm Maternity meeting room
 Obstetric risk management meeting
o Variable dates – D/W Dr L Williams
 Involvement in guideline review
 Involvement in audit and quality improvement
 PROMPT course teaching
 Research – on-going projects
 Midwife epidural teaching programme

Training for obstetric anaesthesia is divided into basic, intermediate,

advanced and higher training in the RCOA 2010 curriculum.

This document refers to basic level training.

Every trainee new to the labour ward should acquaint themselves with the
2018 Obstetric Anaesthesia Handbook as well as the intranet guidelines.
Background reading is essential.
Recommended reading:

 Analgesia, Anaesthesia and Pregnancy, A practical guide; Steve Yentis,

Anne May and Surbhi Malhotra

Every opportunity should be taken to discuss topics with consultants. Once a

particular topic has been discussed, it should be recorded.

The 2010 curriculum provides the formal assessments that are required for
the initial assessment of competence but there are other topics that we feel
should be covered as well as keeping a log of cases undertaken in the initial
period

You need to complete the Initial Assessment of Competence before starting

on calls. It is your responsibility to get this paperwork done. We will
endeavour to deliver the teaching; you need to help us get the paperwork
done.

Paperwork:

 Initial Assessment of Competence for Obstetric Anaesthesia

o Workplace based assessments summary sheet
o Certificate once WPBAs completed
 Additional topics sheet for discussion prior to on calls (RBH document)
 Basic level curriculum WPBAs (2010 curriculum)

There is repetition of topics between what we wish you to discuss prior to on

call and the basic level training WPBAs. Do try to cross-reference them to
help with your paperwork chasing.

Please ensure you complete the obstetric anaesthetic database on the

computer detailing the level of supervision for any procedures to keep an
accurate record of your progress with procedures.

Complete the minimum dataset for starting on labour ward on your induction
which can be found in the Handbook for Obstetric Anaesthesia.
 Assessments for the Initial Assessment for
Competence in Obstetric Anaesthesia
A-CEX
Assessment
Assessment
Code
Basic Competencies for Obstetric Anaesthesia – conduct epidural analgesia for
OB_BTC_A01
labour [12-24 months]
Basic Competencies for Obstetric Anaesthesia – conduct regional anaesthesia for
OB_BTC_A02
caesarean section [12-24 months]
Basic Competencies for Obstetric Anaesthesia – conduct general anaesthesia for
OB_BTC_A03
caesarean section [12-24 months][S]

DOPS
Assessment
Assessment
Code
OB_BTC_D Basic Competencies for Obstetric Anaesthesia – top up epidural for labour analgesia
01 [12-24 months]
OB_BTC_D Basic Competencies for Obstetric Anaesthesia – top up epidural for caesarean section
02 [12-24 months]
OB_BTC_D Basic Competencies for Obstetric Anaesthesia – Perform spinal anaesthesia [12-24
03 months]

CBD
Examine the case-notes. Discuss how the anaesthetic plan was developed. Ask the trainee to explain
their approach to pre-op preparation, choice of induction, maintenance, post op care. Select one of the
following topics and discuss the trainees understanding of the issues in context
Assessment
Assessment
Code
Discuss how changes in the anatomy and physiology due to pregnancy influenced
OB_BTC_C01
the conduct of anaesthesia
OB_BTC_C02 Discuss whether pregnancy influenced the choice of drugs used during anaesthesia
OB_BTC_C03 Discuss how the conduct of general anaesthesia is affected by late pregnancy
Examine the case records of a patient that the trainee has anaesthetised for operative
delivery in a situation where major haemorrhage might be expected. Discuss the
OB_BTC_C04
factors that influence the likelihood of major obstetric haemorrhage, the precautions
that should be taken to deal with it and the principles of its management.
Examine the case records of a patient with pregnancy associated hypertension that
OB_BTC_C05
the trainee has treated. Discuss how this influences anaesthetic management.
Examine the case records of a patient for whom the trainee provided extradural
OB_BTC_C06 analgesia for normal labour. Discuss the methods of pain relief available for normal
delivery.

A copy of the obstetric basic test of competence certificate is shown on the following
page.

DO NOT USE THIS DOCUMENT; IT DOES NOT HAVE THE RCOA WATERMARK.

The official certificate can be downloaded from the secure area of the College website.
The Royal College of Anaesthetists
Initial Assessment of Competence
in Obstetric Anaesthesia
Certificate
This is to certify that:
______________________________________________________________________

GMC number College Reference Number

has satisfactorily passed the workplace assessments and demonstrated the following clinical
learning outcomes for the initial assessment of competence in obstetric anaesthesia:

 Safe administration of epidural/CSE for pain relief in labour

 Safe administration of epidural top-up for an emergency caesarean section
 Safe administration of spinal/CSE for elective or emergency caesarean section
 Safe administration of general anaesthesia for elective or emergency caesarean section

and is now suitable for on call duties in obstetrics.

On ______/_______/_______ (day/month/year).

Final signoff must be done by two Consultant Anaesthetists

Signed:____________________________ Name (Print):________________________

Date:____________

Signed:___________________________ Name (Print):_________________________

Date:____________

Hospital or
department
date stamp
The original of this certificate should be kept by the trainee with copies held by the School of
Anaesthesia and/or hospital. A copy should also be sent to the Training Department at the
Royal College of Anaesthetists

Record of assessments
Competent
Assessment Completion date
Signed/dated
Anaesthesia Clinical Evaluation Exercise

OB_BTC_A01

OB_BTC_A02

OB_BTC_A03

Direct Observation of Procedural Skills

OB_BTC_D01

OB_BTC_D02

OB_BTC_D03

Case Based Discussion

OB_BTC_C01

OB_BTC_C02

OB_BTC_C03

OB_BTC_C04

OB_BTC_C05

OB_BTC_C06

Assessments may be performed by an appropriately trained consultant anaesthetist, non-

consultant career grade doctor or ST3+. All must be registered as a trainer with the College.
 CORE KNOWLEDGE FOR TRAINEES AT THE ROYAL BERKSHIRE
HOSPITAL PRIOR TO ON CALLS

The following pages list the core knowledge and skills necessary for basic
training. This is a list of what we, the obstetric anaesthetists at the RBH, feel
is important to discuss prior to on calls. It is intended to guide our teaching
and discussions on labour ward during your initial time with us. It is your
responsibility to work through these topics and guide the discussions in
combination with the WPBAs for the initial certificate of competence and the
basic level training.

CORE KNOWLEDGE – Basic Sciences

TOPIC Read/discussed/assessed Date

(Tick when completed)
Anatomy of spine/peripheral
nerves
Physiology of pregnancy
Placental transfer of drugs
Aortocaval compression
Drugs and pregnancy
Local Anaesthetics
Gastric function, feeding in
labour

CORE KNOWLEDGE – Analgesia

TOPIC Read/discussed/assessed Date

(Tick when completed)
Relaxation/TENS/entonox
Parenteral opioids (bolus/pca)
Epidural analgesia
Spinal anaesthesia
Combined spinal-epidural
Monitoring of mother and baby
for regional analgesia
Spinal/epidural opioids

CORE KNOWLEDGE – Management of labour and delivery

TOPIC Read/discussed/assessed Date

(Tick when completed)
Normal labour and delivery
Induction and Augmentation
Instrumental delivery
Caesarean section- Epidural
Spinal
GA
Assessment of the pregnant
mother for anaesthetic
Removal of retained placenta
Cricoid pressure
Post-Caesarean analgesia
CORE KNOWLEDGE – Anaesthetic complications

TOPIC Read/discussed/assessed Date

(Tick when completed)
Failed / difficult intubation
Bloody tap
Dural puncture
Postdural puncture headache
Epidural blood patch
Extensive regional blocks
Inadequate regional blocks
Backache
Nerve lesions after regional
anaesthesia
Opioid-induced pruritus
Shivering
Aspiration of gastric contents
Awareness
Air embolism

CORE KNOWLEDGE - Neonatal

TOPIC Read/discussed/assessed Date

(Tick when completed)
Neonatal assessment
Physiology /Pharmacology
Resuscitation
Perinatal mortality
Drugs and breastfeeding

CORE KNOWLEDGE - Maternal Medical Problems

TOPIC Read/discussed/assessed Date
(Tick when completed)
Cardiac Problems
 Valvular
 Dysrhythmias
Respiratory Problems
Renal
Obesity
Skeletal
Haematological
CORE KNOWLEDGE - Obstetric problems

TOPIC Read/discussed/assessed Date

(Tick when completed)
Induction
Oxytocic/tocolytic drugs
Premature labour
Trial of scar
Placenta praevia
Placental abruption
Prolapsed cord
Fetal distress
Intrauterine death
Major obstetric haemorrhage
Collapse on labour ward
CPR maternal
Amniotic fluid embolism
Cholestasis of pregnancy
Acute fatty liver
Pre-eclampsia/eclampsia
Magnesium sulphate
HELLP
Maternal mortality

SKILLS – Communication

TOPIC Read/discussed/assessed Date

(Tick when completed)
Consent/info about GA
Consent/info about epidurals
for labour
Consent/info about regional
techniques for Caesarean
sections
Dealing with problem regionals

SKILLS - Organisational

 Identification of priorities
 Allocation of resources
 Appreciation of when senior help is required
 Familiarity of equipment and environment

SKILLS – Practical

 Sterile technique
 Application of cricoid pressure
 Completion of medical records
 Audit
 Ability to recognise complications of obstetric analgesia and
anaesthesia
Clinical experience
Please keep a record of the cases that you see during your initial training
period.

GENERAL ANAESTHESIA
NUMBER SUPERVISION COMMENTS
1
2
3
4
5
6
7
8
9
10

EPIDURALS
NUMBER SUPERVISION COMMENTS
1
2
3
4
5
6
7
8
9
10

SPINALS
NUMBER SUPERVISION EMERGENCY/ELECTIVE COMMENTS
1
2
3
4
5
6
7
8
9
10
INTERESTING CASES

DATE CASE COMMENTS

10
 Assessment list for LSCS under general anaesthesia.
Trainee Name:

1. Pre operative visit

Introduction and communication with the mother
Assessment of patient including general health, obstetric history, anaesthetic history
Careful assessment of the airway
Discussion of technique including cricoid pressure and post op analgesia
Understanding of the indication for general anaesthesia and probable need for
speed
Premedication
2. Correct checking of:
Complete GA checklist
Anaesthetic machine, airway equipment including airway adjuncts and a tipping
trolley, CMAC videolaryngoscope in theatre
GA and emergency drugs
Consent form
Bloods have been taken for FBC and Group and Save
3. IV cannula and IV fluids running and full monitoring attached
4. Administer Sodium Citrate
5. Careful positioning of the mother including avoidance of aotocaval compression and
neck positioning for ease of intubation
6. Ensure correct personnel are present and ready and WHO check completed
7. Ensure urinary catheter in situ
8. Clean and drape the patient
9. Induction of Anaesthesia
Pre oxygenation
Suction under pillow
Cricoid pressure
Correct drugs and dosages
Intubation (and knowledge of the potential difficulties in pregnancy and the failed
intubation drill)
Commencement of IPPV
10. Maintenance of Anaesthesia
Appropriate administration of inhalational agents and neuromuscular blocking drugs
Maintain ET CO2 4 – 4.5 kPa
Assessment of the patient including clinical signs and non invasive monitoring
especially pre delivery
Use of carbetocin
Administration of IV fluids, antibiotics anti-emetics and analgesia
11. Emergence
Check neuromuscular blockade
Positioning of mother (check bed will tip)
Extubation
Assess post operative pain and treat
Ensure safety of mother prior to transfer back to Labour Ward for recovery
Communication to mother and partner
12 Adequate note keeping
Pre operative assessment and need for GA
GA technique including drugs used and laryngoscopy
Positioning
Timings
Any difficulties
13 Prescription of appropriate post operative drugs
Analgesia
Anti-emetics
Antithrombotics + TEDS
Laxatives
Fluids
NOTES:
Assessors Signature: Assessors name: Date:
 Assessment form for LSCS under regional anaesthesia

Trainee Name: ___________________________________

1 Adequate explanation of the procedure given

2 Correct checking of:
 anaesthetic machine, intubation trolley
 drugs including those for induction of GA
 ranitidine given
3 IV cannula sited and monitoring attached
4 Patient positioned adequately and spaces correctly identified
5 Correct aseptic technique throughout (including mask, hat ,gown and gloves)
6 Infiltration of skin and subcutaneous tissues correctly
7 Subarachnoid space adequately identified
Including knowledge about what to do if difficult or parasthesia elicited
8 Local anaesthetic administered in appropriate dose and speed
9 Positioning of the patient correctly after LA administered and for surgery with obvious lateral tilt
10 Adequate assessment of height and adequacy of block
11 Correct treatment (or knowledge of how to treat) complications/side effects
 Nausea or vomiting
 Hypotension
 High/total block
 Inadequate pain relief
 Blood loss
12 Appropriate administration of :
 vasopressors
 Carbetocin post delivery
 antibiotics
 intravenous fluids
13 Adequate note keeping
 Explanation of what patient told regarding anaesthetic
 Technique of block (needle used, dose given, problems encountered, asepsis)
 Positioning
 Assessment of block pre surgery
 Timing of events
 Summary of any problems
 Comment on patient satisfaction of block
14 Prescription of appropriate post operative drugs
 Analgesia
 Antiemetics
 Antibiotics
 Antithrombotics
 Laxatives
 Opiate antagonists
 Fluids
 Instructions re care with spinal opiates
15 Good explanation and reassurance to the patient throughout surgery
NOTES:

Assessors signature: Assessors name: Date…………….

 Assessment list for the insertion and management of an obstetric lumbar
epidural
Trainee name:

1 Identification of patient and introduction

2 History, examination, investigations:
 Checking notes
 Obstetric history
 Absolute and relative contraindications
 20 minute CTG
3 Equipment and resuscitation
 Presence of qualified midwife
 Location of checked resuscitation equipment
 Location of drugs (ephedrine, atropine, fluids, resuscitation drugs)
4 Explanation of procedure and verbal consent (including risks; headache, nerve
damage, back bruise, motor block, slow labour, instrumental delivery, failure to
work or insert, low BP, nausea and vomiting)
5 IV cannula sited and patent
6 Patient positioned adequately and spaces correctly identified
7 Epidural equipment checked
8 Full aseptic technique (hat, gown, gloves, mask, drapes, chlorhexidine 0.5% spray)
9 Local anaesthetic to skin and subcutaneous tissues
10 Locating the epidural space
 Safe technique with saline
 What to do if paraesthesia , difficulty or dural puncture
11 Catheter inserted and adjusted to correct length (not to withdraw catheter through
needle)
12 Checking location of catheter tip (falling meniscus, gentle aspiration)
 What to do if CSF or blood in catheter
13 Appropriate fixing and labelling of catheter
14 Dosing
 Monitoring attached (including CTG), IV fluid running
 Patient positioning
 Appropriate test dose
 Appropriate questioning and observation during dose (not during
contraction)
 Knowledge of drugs and frequencies of dosing for epidural
15 Correct detection and knowledge of how to treat complications (hypotension, IV
local anaesthetic injection, subarachnoid block, subdural block, acute change in
CTG)
16 Checking and management of blocks
 Normal block
 High block
 Unilateral block
 Missed segment
 No block
 Perineal pain
17 Bladder care
18 Adequate note keeping (history, examination, investigations, explanation, risks,
technique, problems)
19 Prescription of fluids, ranitidine, epidural drugs (for top up and instrumental)
20 Communication throughout (clear instructions and reassurance)
21 Follow up (headache, neurology, bladder, back, effectiveness, satisfaction)
22 Computer database, paper record and K2 completed
Notes

Assessors signature: Assessors name: Date:

 RCOA BASIC LEVEL TRAINING RCOA 2010
WORKPLACE BASED ASSESSMENTS

Obstetrics
Wherever possible, this Basic Level unit of training should occur in a dedicated block. The use of
simulators may assist in the teaching and assessment of some aspects of this section e.g. general
anaesthesia for Caesarean section

Learning outcome:
 To gain knowledge, skills and experience of the treatment of the healthy pregnant woman

Core clinical learning outcomes:

 To pass the formal practical initial assessment of competence in obstetric anaesthesia and,
having achieved this, be able to provide analgesia and anaesthesia as required for the majority of
the women in the delivery suite
 To understand the management of common obstetric emergencies and be capable of performing
immediate resuscitation and care of acute obstetric emergencies [e.g. eclampsia; pre-eclampsia;
haemorrhage], under distant supervision but recognising when additional help is required

NB: All competencies annotated with the letter ‘E’ can be examined in any of
the components of the Primary examination identified in the FRCA
examination blueprint on page B-99.

Knowledge
Assessment
Competence Description GMP
Methods
Recalls/describes the anatomy, physiology and pharmacology
OB_BK_01 A,C,E 1
related to pregnancy and labour [cross ref basic sciences]
Lists common obstetric indications for anaesthetic
OB_BK_02 A,C,E 1
intervention on the delivery suite
Describes the effects of aortocaval compression and how to
OB_BK_03 A,C,E 1,2
avoid it
OB_BK_04 Recalls/describes how to assess fetal well being in utero A,C,E 1,2
OB_BK_05 Discusses the management of pre-eclampsia and eclampsia C,E 1,2
Lists risk factors and describes the management of major
OB_BK_06 C,E 1,2
obstetric haemorrhage
Explains local feeding / starvation policies and the reasons
OB_BK_07 A,C,E 1,2
behind them
OB_BK_08 Explains the thromboprophylaxis requirements in pregnancy A,C,E 1,2
OB_BK_09 Describes the grading of urgency of Caesarean section A,C,E 1,2
Explains why anaesthetic techniques must be modified in the
OB_BK_10 A,C,E 1,2
pregnant patient
Lists methods of analgesia during labour and discusses their
OB_BK_11 A,C,E 1,2
indications and contraindications
Describes epidural or CSE analgesia in labour and
OB_BK_12 recalls/discusses the indications, contraindications and A,C,E 1,2
complications
Explains how to provide regional anaesthesia for operative
OB_BK_13 A,C,E 1
delivery
Understands the need to call for assistance after several
OB_OK_14 A,C,E 1,2,3
attempts at placement of regional blocks proves unsuccessful
Describes the immediate management of accidental dural
OB_OK_15 A,C,E 1
puncture
OB_BK_16 Recalls/describes maternal and basic neonatal resuscitation A,C,E 1,2
Knowledge
Assessment
Competence Description GMP
Methods
Describes how to access local maternity guidelines and the
OB_BK_17 A,C,E 1,2
value of having these guidelines
Skills
Assessment
Competence Description GMP
Methods
Undertakes satisfactory preoperative assessment of the
OB_BS_01 A,D 1
pregnant patient
Demonstrates the ability to clearly explain and prepare an
OB_BS_02 A,C,D 1,3,4
obstetric patient for surgery
Demonstrates the use of techniques to avoid aorto-caval
OB_BS_03 D 1
compression
Demonstrates the ability to provide epidural analgesia in
OB_BS_04 A,D,M 1
labour
Demonstrates the ability to provide spinal anaesthesia for
OB_BS_05 A,D 1
caesarean section
Demonstrates the ability to convert epidural analgesia to
OB_BS_06 A,C,D 1
epidural anaesthesia for surgical intervention
Demonstrates the ability to provide general anaesthesia for
OB_BS_07 A,C,D,S 1
caesarean section [S]
Demonstrates an appropriate choice of anaesthesia/analgesia
OB_BS_08 C 1
for instrumental delivery
Demonstrates an appropriate choice of anaesthesia for
OB_BS_09 C 1,2
retained placenta
Demonstrates safe and effective management of post-delivery
OB_BS_10 C,M 1
pain relief
Demonstrates ability to recognise when an obstetric patient is
OB_BS_11 C,M 1
sick and the need for urgent assistance
Demonstrates the ability to provide advanced life support for
OB_BS_12 D,S 1
a pregnant patient [S]
Demonstrates the ability to provide basic neonatal life support
OB_BS_13 D,S 1
[S]
Obtains the Initial Assessment of Competence in Obstetric
OB_BS_14 A,C,D 1,2,3,4
Anaesthesia