1. Difficult airway in obstetrics
University of Gondar
College of medicine and health science
department of anesthesia
Misganaw M
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2. INTRODUCTION
 The difficult airway is a clinical situation which includes either
difficulty with mask ventilation or tracheal intubation,
laryngoscopic.
 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.
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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
patients.
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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
intubations.
 However, most airway tests are unreliable so we will
inevitably be faced with some unexpectedly difficult or
impossible intubations.
o The next best option is to have a robust plan for the
management of such a situation.
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6. WHY IS OBSTETRIC AIRWAYMANAGEMENT MORE
DIFFICULT?
 Anatomical and Physiological Factors
 Human Factors
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7. PRACTICAL APPROACH TO OBSTETRIC
AIRWAY MANAGEMENT
 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
access.
 Several factors have been identified that may predict airway
difficulties in this population
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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
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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.
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12. PREOXYGENATION
 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
intubation attempts.
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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
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14. ELECTIVE USE OF SADS FOR CAESAREAN
SECTION
 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
section.
 While significant airway-related complications have not been
reported in such studies, high-risk women (including those with
obesity) were generally excluded .
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15.  ILMA /prosealLMA has been used in parturients after failed
intubation
–Gonzales: Rev Esp Anesthesiol
Reanim 2005;52(1):56-57
– M i n i v i l l e A n e s t h A n a l g
2004;99(6):1873
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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
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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
airway.
 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 (
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