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
- Division Head of Anesthesiology, Critical Care and Pain Medicine
- The University of Texas MD Anderson Cancer Center
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 [6,8-13]. 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) [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 . 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) .
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- 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