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Airway management of the pregnant patient at delivery

Michaela K Farber, MD
Lorraine Chow, MD
Bhavani-Shankar Kodali, MD
Section Editors
David L Hepner, MD
Carin A Hagberg, MD
Deputy Editor
Marianna Crowley, MD


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 [1]. 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".)


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 [7], 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 [6,8-13]. In contrast, in a retrospective study of 13,380 surgical patients, only 0.045 percent had failed intubation [11].

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) [14-16].

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 [14]. 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) [14].

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Literature review current through: Oct 2017. | This topic last updated: Feb 07, 2017.
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