1. Difficult airway in obstetrics
University of Gondar
College of medicine and health science
department of anesthesia
The difficult airway is a clinical situation which includes either
difficulty with mask ventilation or tracheal intubation,
Obstetric patients are at increased risk of failed tracheal
intubation during obstetric GA because of a number of unique
clinical situational, situational factors.
Difficult or failed intubations will occur, and the only safe way to
manage them is to be well prepared . 2
3. What is the Incidence of Difficult Intubation, Failed Intubation
and pulmonary aspiration in Obstetrics patients?
The incidence of failed tracheal intubation in the
general surgical population is approximately 1:2200,
but the incidence in the obstetric population may be as
high as 1:250.
4. Failed Intubation occurs in approximately 0.13% to
0.35% or 1:750 to 1:280, of obstetric patients versus
1:2,000 for all patients.
Incidence of Pulmonary aspiration of gastric contents
for obstetric patients is 1:500-400 versus 1:2,000 for all
5. Failed intubation is an important factor contributing to both
maternal and fetal mortality.
Ideally we should be able to predict, and plan for, all difficult
However, most airway tests are unreliable so we will
inevitably be faced with some unexpectedly difficult or
o The next best option is to have a robust plan for the
management of such a situation.
6. WHY IS OBSTETRIC AIRWAYMANAGEMENT MORE
Anatomical and Physiological Factors
7. PRACTICAL APPROACH TO OBSTETRIC
Planning and Preparation for Safe Obstetric GA
important components of safe obstetric airway management
include adequate and timely
airway assessment, fasting status,
pharmacologic aspiration prophylaxis,
optimal patient positioning, adequate preoxygenation,
and provision of a secure airway 7
8. AIRWAY ASSESSMENT
every woman undergoing obstetric surgery should have a
documented airway assessment.
This should highlight potential difficulties with tracheal
intubation as well as potential difficulties with face mask and
supraglottic airway device (SAD) placement and front-of-neck
Several factors have been identified that may predict airway
difficulties in this population
10. PULMONARY ASPIRATION RISK REDUCTION
Gastric emptying in a nonlabouring pregnant woman is similar
to that in a nonpregnant woman; however, gastric emptying is
delayed by labour and opioid analgesia.
The use of point-of-care ultrasound (US) assessment of
gastric contents to individualise the risk of regurgitation in
obstetric patients has recently been described
11. PATIENT POSITIONING
A 20 to 30 degree head-up position may facilitate insertion
of the laryngoscope, improve the view of the glottis,
increase functional residual capacity (FRC), and reduce the
risk of gastric regurgitation.
Currently, there is interest in alternative techniques to provide
preoxygenation and/or apnoeic oxygenation during tracheal
intubation in both nonobstetric and obstetric patients.
Insufflation of oxygen at 5 L/min via nasal cannula may prolong
the apneic time by maintaining bulk flow of oxygen during
13. Cricoid pressure
Controversies with the use of CP
CP often not correctly applied
CP can cause a difficult airway/FI
CP may compromise mask ventilation
CP effectiveness > 4mins is questionable
NAP4 recommended continued use
of CP for RSI
14. ELECTIVE USE OF SADS FOR CAESAREAN
Tracheal intubation following RSI is generally recommended in
the obstetric patient.
However, there are a number of reports of the elective use of
SADs in fasted patients undergoing elective caesarean
While significant airway-related complications have not been
reported in such studies, high-risk women (including those with
obesity) were generally excluded .
15. ILMA /prosealLMA has been used in parturients after failed
–Gonzales: Rev Esp Anesthesiol
– M i n i v i l l e A n e s t h A n a l g
16. DIRECT AND INDIRECT (VIDEO) LARYNGOSCOPY
New disposable intubating laryngoscope
Designed to provide a view of the glottis without alignment
of oral, pharyngeal, and tracheal axis
VL shown to be superior to conventional laryngoscopy
23. EXTUBATION AND POSTOPERATIVE CARE
Focus on airway management must continue until the patient
has recovered from GA and is able to maintain their own
The anaesthetist should remain vigilant, and the obstetric
patient should be extubated awake in the left lateral or head-
up position with full reversal of neuromuscular blockade (