Airway management of the pregnant patient at delivery
- Michaela K Farber, MD
Michaela K Farber, MD
- Instructor of Anesthesia
- Harvard Medical School
- Lorraine Chow, MD
Lorraine Chow, MD
- Clinical Assistant Professor
- University of Calgary
- Bhavani-Shankar Kodali, MD
Bhavani-Shankar Kodali, MD
- Associate Professor of Anesthesia
- Harvard Medical School
- Section Editors
- David L Hepner, MD
David L Hepner, MD
- Section Editor — Obstetric Anesthesia
- Associate Professor of Anaesthesia
- Harvard Medical School
- Carin A Hagberg, MD
Carin A Hagberg, MD
- Section Editor — Airway Management
- Joseph C Gabel Professor and Chair, Department of Anesthesiology
- The University of Texas Medical School at Houston
The majority of pregnant women deliver without the need for airway and ventilatory assistance; however, when general anesthesia is required, the anatomic and physiologic changes of pregnancy and labor can contribute to difficulty with airway management, which increases the risk of maternal morbidity and mortality. The most common indication for endotracheal intubation of a pregnant patient is emergency cesarean delivery due to a nonreassuring fetal heart rate pattern . Additional indications include a failed regional technique prior to a cesarean delivery, a high block from a neuraxial anesthetic, local anesthetic (LA) systemic toxicity, respiratory and neurologic emergencies, and maternal cardiac arrest. This topic will discuss airway management of pregnant women at delivery, with a focus on management of the difficult airway. Other anesthetic considerations for cesarean delivery, and for pregnant women undergoing non-obstetric surgery, are discussed elsewhere. (See "Anesthesia for cesarean delivery" and "Management of the pregnant patient undergoing nonobstetric surgery".)
INCIDENCE AND CONSEQUENCES OF AIRWAY PROBLEMS
Difficult intubation has been reported in 0.45 to 5.7 percent of intubations in pregnant women [2-6]. Although a similar proportion of the general surgical population (5.8 percent) has difficult intubations , the consequences of difficult intubation can be greater in the obstetric population.
Failed intubation is much less common than difficult intubation, but it occurs much more frequently in obstetric patients than in surgical patients. Several observational studies of obstetric patients have reported failed intubation rates of 0.26 to 0.4 percent [6,8-12]. In contrast, in a retrospective study of 13,380 surgical patients, only 0.045 percent had failed intubation .
Maternal mortality — Anesthesia-related mortality in obstetric patients is most often due to respiratory events. Respiratory problems occur not just during induction of general anesthesia, but also at emergence and recovery, or in relation to regional anesthetic complications (eg, high spinal anesthesia) [13-15].
●In an analysis comparing anesthesia-related maternal deaths in the United States from 1991 to 1996 with those from 1997 to 2002, while cesarean fatality rates under general anesthesia fell (from 16.8 to 6.5 per million) and those under regional anesthesia rose (from 2.5 to 3.8 per million), respiratory issues remained prominent . Overall, the leading causes of anesthesia-related pregnancy deaths for 1991 to 2002 were induction problems or intubation failure (23 percent), respiratory failure (20 percent), and high spinal or epidural block (16 percent) .
- Vasdev GM, Harrison BA, Keegan MT, Burkle CM. Management of the difficult and failed airway in obstetric anesthesia. J Anesth 2008; 22:38.
- McKeen DM, George RB, O'Connell CM, et al. Difficult and failed intubation: Incident rates and maternal, obstetrical, and anesthetic predictors. Can J Anaesth 2011; 58:514.
- Djabatey EA, Barclay PM. Difficult and failed intubation in 3430 obstetric general anaesthetics. Anaesthesia 2009; 64:1168.
- Rocke DA, Murray WB, Rout CC, Gouws E. Relative risk analysis of factors associated with difficult intubation in obstetric anesthesia. Anesthesiology 1992; 77:67.
- Quinn AC, Milne D, Columb M, et al. Failed tracheal intubation in obstetric anaesthesia: 2 yr national case-control study in the UK. Br J Anaesth 2013; 110:74.
- McDonnell NJ, Paech MJ, Clavisi OM, et al. Difficult and failed intubation in obstetric anaesthesia: an observational study of airway management and complications associated with general anaesthesia for caesarean section. Int J Obstet Anesth 2008; 17:292.
- Shiga T, Wajima Z, Inoue T, Sakamoto A. Predicting difficult intubation in apparently normal patients: a meta-analysis of bedside screening test performance. Anesthesiology 2005; 103:429.
- Barnardo PD, Jenkins JG. Failed tracheal intubation in obstetrics: a 6-year review in a UK region. Anaesthesia 2000; 55:690.
- Rahman K, Jenkins JG. Failed tracheal intubation in obstetrics: no more frequent but still managed badly. Anaesthesia 2005; 60:168.
- Hawthorne L, Wilson R, Lyons G, Dresner M. Failed intubation revisited: 17-yr experience in a teaching maternity unit. Br J Anaesth 1996; 76:680.
- Samsoon GL, Young JR. Difficult tracheal intubation: a retrospective study. Anaesthesia 1987; 42:487.
- Kinsella SM, Winton AL, Mushambi MC, et al. Failed tracheal intubation during obstetric general anaesthesia: a literature review. Int J Obstet Anesth 2015; 24:356.
- Hawkins JL, Chang J, Palmer SK, et al. Anesthesia-related maternal mortality in the United States: 1979-2002. Obstet Gynecol 2011; 117:69.
- Mhyre JM, Riesner MN, Polley LS, Naughton NN. A series of anesthesia-related maternal deaths in Michigan, 1985-2003. Anesthesiology 2007; 106:1096.
- McClure JH, Cooper GM, Clutton-Brock TH, Centre for Maternal and Child Enquiries. Saving mothers' lives: reviewing maternal deaths to make motherhood safer: 2006-8: a review. Br J Anaesth 2011; 107:127.
- Izci B, Vennelle M, Liston WA, et al. Sleep-disordered breathing and upper airway size in pregnancy and post-partum. Eur Respir J 2006; 27:321.
- Pilkington S, Carli F, Dakin MJ, et al. Increase in Mallampati score during pregnancy. Br J Anaesth 1995; 74:638.
- Kodali BS, Chandrasekhar S, Bulich LN, et al. Airway changes during labor and delivery. Anesthesiology 2008; 108:357.
- Boutonnet M, Faitot V, Katz A, et al. Mallampati class changes during pregnancy, labour, and after delivery: can these be predicted? Br J Anaesth 2010; 104:67.
- Basaranoglu G, Columb M, Lyons G. Failure to predict difficult tracheal intubation for emergency caesarean section. Eur J Anaesthesiol 2010; 27:947.
- American Society of Anesthesiologists Task Force on Obstetric Anesthesia. Practice guidelines for obstetric anesthesia: an updated report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia. Anesthesiology 2007; 106:843.
- Wong CA, Loffredi M, Ganchiff JN, et al. Gastric emptying of water in term pregnancy. Anesthesiology 2002; 96:1395.
- Wong CA, McCarthy RJ, Fitzgerald PC, et al. Gastric emptying of water in obese pregnant women at term. Anesth Analg 2007; 105:751.
- Committee on Obstetric Practice, American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 441: Oral intake during labor (Reaffirmed February 2016). Obstet Gynecol 2009; 114:714.
- Palanisamy A, Mitani AA, Tsen LC. General anesthesia for cesarean delivery at a tertiary care hospital from 2000 to 2005: a retrospective analysis and 10-year update. Int J Obstet Anesth 2011; 20:10.
- Biro P. Difficult intubation in pregnancy. Curr Opin Anaesthesiol 2011; 24:249.
- Lebowitz PW, Shay H, Straker T, et al. Shoulder and head elevation improves laryngoscopic view for tracheal intubation in nonobese as well as obese individuals. J Clin Anesth 2012; 24:104.
- Lee SW, Khaw KS, Ngan Kee WD, et al. Haemodynamic effects from aortocaval compression at different angles of lateral tilt in non-labouring term pregnant women. Br J Anaesth 2012; 109:950.
- Weingart SD, Levitan RM. Preoxygenation and prevention of desaturation during emergency airway management. Ann Emerg Med 2012; 59:165.
- Ramachandran SK, Cosnowski A, Shanks A, Turner CR. Apneic oxygenation during prolonged laryngoscopy in obese patients: a randomized, controlled trial of nasal oxygen administration. J Clin Anesth 2010; 22:164.
- Taha SK, Siddik-Sayyid SM, El-Khatib MF, et al. Nasopharyngeal oxygen insufflation following pre-oxygenation using the four deep breath technique. Anaesthesia 2006; 61:427.
- Sakles JC, Mosier JM, Patanwala AE, et al. First Pass Success Without Hypoxemia Is Increased With the Use of Apneic Oxygenation During Rapid Sequence Intubation in the Emergency Department. Acad Emerg Med 2016; 23:703.
- Chiron B, Laffon M, Ferrandiere M, et al. Standard preoxygenation technique versus two rapid techniques in pregnant patients. Int J Obstet Anesth 2004; 13:11.
- Harmer M. Difficult and failed intubation in obstetrics. Int J Obstet Anesth 1997; 6:25.
- Davies JM, Weeks S, Crone LA, Pavlin E. Difficult intubation in the parturient. Can J Anaesth 1989; 36:668.
- Lewin SB, Cheek TG, Deutschman CS. Airway management in the obstetric patient. Crit Care Clin 2000; 16:505.
- Ezri T, Szmuk P, Evron S, et al. Difficult airway in obstetric anesthesia: a review. Obstet Gynecol Surv 2001; 56:631.
- American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2003; 98:1269.
- Sun DA, Warriner CB, Parsons DG, et al. The GlideScope Video Laryngoscope: randomized clinical trial in 200 patients. Br J Anaesth 2005; 94:381.
- Stroumpoulis K, Pagoulatou A, Violari M, et al. Videolaryngoscopy in the management of the difficult airway: a comparison with the Macintosh blade. Eur J Anaesthesiol 2009; 26:218.
- Vaida SJ, Pott LM, Budde AO, Gaitini LA. Suggested algorithm for management of the unexpected difficult airway in obstetric anesthesia. J Clin Anesth 2009; 21:385.
- Awan R, Nolan JP, Cook TM. Use of a ProSeal laryngeal mask airway for airway maintenance during emergency Caesarean section after failed tracheal intubation. Br J Anaesth 2004; 92:144.
- McCrirrick A. The laryngeal mask airway for failed intubation at caesarean section. Anaesth Intensive Care 1991; 19:135.
- Bailey SG, Kitching AJ. The Laryngeal mask airway in failed obstetric tracheal intubation. Int J Obstet Anesth 2005; 14:270.
- Han TH, Brimacombe J, Lee EJ, Yang HS. The laryngeal mask airway is effective (and probably safe) in selected healthy parturients for elective Cesarean section: a prospective study of 1067 cases. Can J Anaesth 2001; 48:1117.
- Halaseh BK, Sukkar ZF, Hassan LH, et al. The use of ProSeal laryngeal mask airway in caesarean section--experience in 3000 cases. Anaesth Intensive Care 2010; 38:1023.
- Yao WY, Li SY, Sng BL, et al. The LMA Supreme™ in 700 parturients undergoing Cesarean delivery: an observational study. Can J Anaesth 2012; 59:648.
- Munnur U, Suresh MS. Airway problems in pregnancy. Crit Care Clin 2004; 20:617.
- Fenton PM, Reynolds F. Life-saving or ineffective? An observational study of the use of cricoid pressure and maternal outcome in an African setting. Int J Obstet Anesth 2009; 18:106.
- Vanner R. Cricoid pressure. Int J Obstet Anesth 2009; 18:103.
- Priebe HJ. Cricoid pressure: an expert's opinion. Minerva Anestesiol 2009; 75:710.
- Ovassapian A, Salem MR. Sellick's maneuver: to do or not do. Anesth Analg 2009; 109:1360.
- Lerman J. On cricoid pressure: "may the force be with you". Anesth Analg 2009; 109:1363.
- Apfelbaum JL, Hagberg CA, Caplan RA, et al. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2013; 118:251.
- Mushambi MC, Kinsella SM, Popat M, et al. Obstetric Anaesthetists' Association and Difficult Airway Society guidelines for the management of difficult and failed tracheal intubation in obstetrics. Anaesthesia 2015; 70:1286.
- Pinksy J, Hagberg CA. Combination Techniques. In: A Practical Guide to the Difficult Airway, Oxford University Press, New York 2012. p.143.
- Munnur U, de Boisblanc B, Suresh MS. Airway problems in pregnancy. Crit Care Med 2005; 33:S259.
- Kuczkowski KM, Reisner LS, Benumof JL. Airway problems and new solutions for the obstetric patient. J Clin Anesth 2003; 15:552.
- Chadwick IS, Vohra A. Anaesthesia for emergency caesarean section using the brain laryngeal airway. Anaesthesia 1989; 44:261.
- Gataure PS, Hughes JA. The laryngeal mask airway in obstetrical anaesthesia. Can J Anaesth 1995; 42:130.
- McClune S, Regan M, Moore J. Laryngeal mask airway for caesarean section. Anaesthesia 1990; 45:227.
- Hignett R, Fernando R, McGlennan A, et al. A randomized crossover study to determine the effect of a 30° head-up versus a supine position on the functional residual capacity of term parturients. Anesth Analg 2011; 113:1098.
- STANDARDS FOR POSTANESTHESIA CARE http://www.asahq.org/For-Members/Standards-Guidelines-and-Statements.aspx (Accessed on September 03, 2013).
- Hood DD, Dewan DM. Anesthetic and obstetric outcome in morbidly obese parturients. Anesthesiology 1993; 79:1210.
- Palmer CM. Continuous spinal anesthesia and analgesia in obstetrics. Anesth Analg 2010; 111:1476.
- Arkoosh VA, Palmer CM, Yun EM, et al. A randomized, double-masked, multicenter comparison of the safety of continuous intrathecal labor analgesia using a 28-gauge catheter versus continuous epidural labor analgesia. Anesthesiology 2008; 108:286.
- Faure E, Moreno R, Thisted R. Incidence of postdural puncture headache in morbidly obese parturients. Reg Anesth 1994; 19:361.
- Izci B, Riha RL, Martin SE, et al. The upper airway in pregnancy and pre-eclampsia. Am J Respir Crit Care Med 2003; 167:137.
- Siddiqui S, Goodman N, McKenna S, et al. Pre-eclampsia is associated with airway hyperresponsiveness. BJOG 2008; 115:520.
- INCIDENCE AND CONSEQUENCES OF AIRWAY PROBLEMS
- Maternal mortality
- ANATOMIC AND PHYSIOLOGIC CHANGES
- GENERAL PRINCIPLES FOR PREVENTION OF AIRWAY DIFFICULTIES
- Identify patients with a difficult airway
- - Airway assessment
- Use regional anesthesia
- Prepare emergency equipment
- Reduce the risk of aspiration
- Preparation of personnel
- PREPARATION FOR AIRWAY MANAGEMENT
- Patient positioning
- Available airway equipment
- - Basic intubation equipment
- - Difficult intubation equipment
- Video laryngoscopes
- Intubating LMA
- - Equipment for failed intubation
- Cricothyrotomy kit
- Transtracheal jet ventilation
- MANAGEMENT OF THE ROUTINE AIRWAY
- MANAGEMENT OF THE DIFFICULT AIRWAY
- Overall approach
- Anticipated difficult intubation
- - Choice of awake technique
- - Sedation for awake intubation
- - Topicalization for awake intubation
- Unanticipated difficult intubation
- - Cannot intubate, can ventilate, no fetal distress
- - Cannot intubate, can ventilate, fetal distress
- - Cannot intubate, cannot ventilate
- Extubation of the patient with a difficult airway
- SELECTED PATIENT POPULATIONS
- Morbidly obese parturient
- Preeclamptic/eclamptic parturient
- SUMMARY AND RECOMMENDATIONS