Featured OB Problem-Based Learning Discussion (PBLD)

Cognitive Aids in Obstetric Crises

Authors: Ayumi Maeda, MD, Rebecca D. Minehart, MD

Institution: Massachusetts General Hospital, Boston

This PBLD was peer-reviewed by a panel of experts from the Society of Obstetric Anesthesia and Perinatology (SOAP) and has been endorsed by the SOAP Education Committee. 

Learners should identify a faculty mentor and walk through the case together, after perusing the pre-course work. Tweet your comments and questions using the links below, and experts will weigh in.

Required pre-work: Reading List
  1. Vanden Hoek TL, Morrison LJ, Shuster M, Donnino M, Sinz E, Lavonas EJ, Jeejeebhoy FM, Gabrielli A. Part 12: cardiac arrest in special situations: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010;122:S829–61
  2. Lipman S, Cohen S, Einav S, Jeejeebhoy F, Mhyre JM, Morrison LJ, Katz V, Tsen LC, Daniels K, Halamek LP, Suresh MS, Arafeh J, Gauthier D, Carvalho JC, Druzin M, Carvalho B; Society for Obstetric Anesthesia and Perinatology. The Society for Obstetric Anesthesia and Perinatology consensus statement on the management of cardiac arrest in pregnancy. Anesth Analg 2014;118:1003–16
  3. Berkenstadt H, Ben-Menachem E, Dach R, Ezri T, Ziv A, Rubin O, Keidan I. Deficits in the Provision of Cardiopulmonary Resuscitation During Simulated Obstetric Crises: Results from the Israeli Board of Anesthesiologists. Anesth Analg 2012;115:1122–6
  4. Lewis G. Why Mothers Die 2000-2002 Report on Confidential Enquiries into Maternal Deaths in the United Kingdom. London: RCOG Press; 2004
  5. Davies JM, Posner KL, Lee LA, Cheney FW, Domino KB: Liability associated with obstetric anesthesia: A closed claims analysis. Anesthesiology 2009; 110:131–9
  6. Goldhaber-Fiebert, S. N., Howard, S. K. Implementing Emergency Manuals: Can Cognitive Aids Help Translate Best Practices for Patient Care During Acute Events? Anesth Analg 2013; 117 (5): 1149-1161
  7. Marshall SD. The use of cognitive aids during emergencies in anesthesia: a review of the literature. Anesth Analg 2013 Nov;117(5):1162-71
  8. Neal JM, Hsiung RL, Mulroy MF, et al. ASRA checklist improves trainee performance during a simulated episode of local anesthetic systemic toxicity. Reg Anesth Pain Med 2012; 37:8–15
  9. Marshall SD, Mehra R. The effects of a displayed cognitive aid on non-technical skills in a simulated ‘can’t intubate, can’t oxygenate’ crisis. Anaesthesia 2014 Jul;69(7):669-77
  10. Stiegler MP, Tung A. Cognitive processes in anesthesiology decision making. Anesthesiology 2014 Jan;120(1):204-17
  11. Nelson KL, Shilkofski NA, Haggerty J, Hunt EA. The use of a cognitive aid during simulated pediatric cardiopulmonary arrests. Sim Healthcare 2008; 3: 138–45
  12. Burden AR, Carr ZJ, Staman GW, Littman JJ, Torjman MC. Does every code need a “reader?” improvement of rare event management with a cognitive aid “reader” during a simulated emergency: a pilot study. Simul Healthc 2012 Feb;7(1):1-9
  13. Bould MD, Hayter MA, Campbell DM, Chandra DB, Joo HS, Naik VN. Cognitive aid for neonatal resuscitation: a prospective single-blinded randomized controlled trial. Br J Anaesth 2009 Oct;103(4):570-5.
  14. Siassakos D, Bristowe K, Draycott TJ, Angouri J, Hambly H, Winter C, Crofts JF, Hunt LP, Fox R. Clinical efficiency in a simulated emergency and relationship to team behaviours: a multisite cross-sectional study. BJOG 2011 Apr;118(5):596-607
  15. Preventing infant death and injury during delivery. Sentinel Event Alert 2004 Jul 21;(30):1-3.
  16. Gaba DM. Perioperative cognitive aids in anesthesia: what, who, how, and why bother? Anesth Analg 2013 Nov;117(5):1033-6
Learning objectives: At the conclusion of this session, the fellow will be able to:
  1. Describe the current evidence for use of cognitive aids during crises
  2. Evaluate pros and cons of using cognitive aids
  3. Create a personal version of a cognitive aid for an obstetric crisis and compare to existing cognitive aids
Instructions for Faculty Mentor:

Before proceeding with the case, perform an assessment of your fellow’s prior review of the teaching materials and current understanding of topic. Review key points of learning, clarify any questions, and identify areas for further investigation by the fellow.

Case stem:

A 32 year old G2P1 with a history of a cesarean delivery was admitted at 38 weeks estimated gestational age for a trial of labor after cesearean delivery (TOLAC). She is 61 inches tall, weighs 70kg and has no significant past medical history. Epidural was placed and her labor pain has been well controlled, but her labor has failed to progress and now you are called for a cesarean delivery.

After placing the patient in left uterine displacement (LUD), and confirming negative aspiration of the epidural catheter for blood or CSF, you bolus 5cc of buffered 2% Lidocaine with epinephrine through her epidural, and follow by another 5cc of the same solution 5 minutes later. One minute after the second bolus, the patient starts to complain of discomfort in her abdomen, pointing to the region of her suprapubic area, for which you bolus another 5cc of the lidocaine solution. 10 seconds later, she suddenly becomes unresponsive on her bed. She is now apneic and pulseless.

Step 1 of 8


Model Discussion

A crisis is defined as a time-sensitive situation in which intervention must occur rapidly in order to change the patient’s clinical course. In such cases, it is vital that the patient care team comes together to deliver comprehensive and rapid care to avoid worsening outcomes for both mother and fetus. While the patient case above was one of maternal cardiac arrest, there are many obstetric crises that occur which have specific treatments to hopefully avoid the outcome of cardiopulmonary arrest.

Anesthesia care frequently requires rapid, complex decisions that are most susceptible to decision errors (36), and while we may each build our own expertise in certain areas, no anesthesiologist is expert at managing all aspects of all critical events. Moreover, stressful situations have been shown to negatively impact multiple aspects of human memory, including retrieval of inert knowledge, working memory for calculations, and prospective memory for future tasks (37). This underscores the importance of identifying and reliably training with additional rapidly-accessible tools such as cognitive aids.

Cognitive aids are prompts designed to help users complete a task or series of tasks. They may take the form of posters, flowcharts, checklists, or even mnemonics. It has been suggested that the use of cognitive aids improves performance and patient outcomes during anesthetic emergencies (38). Previous research has shown that the presence of a cognitive aid can improve performance in the simulated management of a rare, high-stakes scenario such as maternal cardiac arrest and malignant hyperthermia (39). A cognitive aid would theoretically guide clinicians under stressful situations through a sequence of complex steps and prevent them from omitting key actions (40). It is important to promote throughout each organization’s culture that the use of these aids is meant to be viewed as a sign of strength and wisdom instead of a sign of weakness and lack of intelligence (41).

Cognitive aids form one component of the larger picture of crisis resource management, which includes other important items such as cross-monitoring, clear and effective communication, mobilizing and managing resources, establishing role clarity, and calling for help early (42). Checklists and similar algorithmic cognitive aids are increasingly popular as decision support tools for critical events. Use of such aids may be effective in promoting better decisions and mitigating the influence of nonrational cognitive factors such as bias.

Simulation studies suggest checklists may help medical teams perform optimally during emergencies (43); however, periodic training is necessary in order to familiarize health care provider teams with their use (44). Incomplete or misleading cognitive aids (such as inaccurate or poorly designed aids), or incorrect use of cognitive aids, may distract clinicians and lead to worse performance than without them (45). It has also been suggested that the introduction of an unfamiliar cognitive aid may lead to a reduction in the volume of communication within the team (46) , especially when a code leader attempts to read a cognitive aid and subsequently becomes task saturated by trying to perform too many simultaneous actions. Therefore, it has been recommended that a code leader designate a team member to serve as the “reader” of the cognitive aid during crises so that interventions from the checklist can be read aloud and cross-checked (47).

The critical determinants to enable the successful development and use of cognitive aids include 1) accurate content, 2) user-friendly design, 3) iterative testing using simulation, 4) repeated familiarization and training, 5) accessibility, and 6) the use of a reader (48). There is a need for larger prospective trials of the effect of aids on task completion, practitioners’ team behaviors, and overall team functioning.

As a separate exercise, we invite you to create your own personal version of a cognitive aid for a specific obstetric crisis. Is there already an existing cognitive aid for that particular obstetric crisis? If so, how does yours compare? If no cognitive aid exists, consider turning your work into a publication to better serve our community of providers.


  1. Stiegler et al Anesthesiology 2014
  2. Goldhaber-Fiebert and Howard A&A 2013
  3. Marshall et al A&A 2013
  4. Berkenstadt et al..
  5. Marshall et al A&A 2013
  6. Gaba A&A November 2013
  7. Gaba DM, Fish KJ, Howard SK, Burden A. Chapter 2: Principles of crisis resource management. In: Crisis Management in Anesthesiology, 2nd ed. Saunders, 2014.
  8. Marshall et al A&A 2013 and Berkenstadt et al.
  9. Goldhaber-Fiebert and Howard, Marshall et al A&A 2013
  10. Marshall A&A 2013
  11. Burden et al
  12. Burden et al 2012
  13. Goldharber-Fiebert and Howard A&A 2013