The ability to maintain a patent airway, provide adequate oxygenation, and place an endotracheal tube (ETT) remains a major concern for airway practitioners. Despite many equipment advances and the development of airway algorithms to guide care, management of the obstetric airway is still a cause for concern. Obstetrical anesthesia is a high-risk practice that is replete with medico-legal liability and laden with clinical challenges. On the obstetric service, the practitioner is required to provide safe anesthesia care to mother and baby, both of whom have unique and demanding anatomical and physiological requirements. The purpose of this chapter is to briefly review the status of maternal morbidity/mortality, highlight the principal reasons that airways of parturients might be difficult to manage, and review current guidelines and algorithms for the management of the obstetrical airway.
Underpinning all discussion is the critical importance of being prepared cognitively for the unexpected occurrence and being facile with appropriate emergency airway equipment. Early consultation for anesthesia intervention, and airway assessment of obstetric patients at high risk for operative intervention, particularly parturients who may be obese or have advanced maternal age, remain a key preventative pillar of care. Of equal importance is teamwork between the anesthesia practitioner, the labor and delivery nurses, and the obstetrician. Improved perioperative training of labor and delivery unit support staff (including anesthesia resources for airway management during and after general anesthesia) are important clinical care considerations. Practicing difficult airway scenarios is invaluable. Being unprepared will certainly guarantee failure.
MATERNAL MORBIDITY AND MORTALITY
Discuss the Anesthetic-Related Morbidity and Mortality of Parturients
Women continue to experience preventable pregnancy-related deaths, with airway management being a significant contributor in developed countries.1–3 These anesthesia-related deaths are particularly catastrophic, because many of these anesthetics are elective and are administered to young otherwise well mothers.
In 1985, a unique perspective on anesthesia morbidity and mortality was unveiled with the institution of the American Society of Anesthesiologists (ASA) Closed Claims Project database. The data from this project are an accumulation of personal damage insurance claims filed against anesthesiologists and subsequently settled.4 Of the nearly 6500 cases in the database at that time, 12% were associated with obstetrical anesthesia care, and nearly three-fourths of these claims were associated with cesarean section. Critical events involving the respiratory system were the most common precipitating events in the obstetrical files. Trauma from repeated attempts at intubation was recognized as an issue of particular hazard.
Cases from the same ASA Closed Claims Project database between 1990 and 2003 were reviewed in 2009 and the review revealed 426 cases associated with obstetric anesthesia, with 58% of these claims associated with cesarean section. Maternal deaths and brain injury during this period occurred most frequently with high blocks during regional anesthesia, half of which occurred during placement for a vaginal delivery. While these may be attributable to ...