The ability to maintain a patent airway, provide adequate ventilation, and place an endotracheal tube remains a major concern for airway practitioners. There is no location that produces more anxiety in this regard than labor and delivery. Obstetrical anesthesia is a high-risk practice that is replete with medicolegal liability and laden with clinical challenges. On the obstetric service, the practitioner is required to provide safe anesthesia care to two patients, 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 propose an algorithm 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.
49.2.1 Discuss the Anesthetic-Related Morbidity and Mortality of Parturients
Women continue to experience preventable pregnancy-related deaths, and anesthesia is the seventh leading cause of such mortality in the United States.1 These anesthesia-related deaths are particularly catastrophic, because many of these anesthetics are elective and are administered to young, otherwise well, mothers.
Hawkins and her colleagues characterized obstetrical anesthesia deaths in the United States by specific cause, relationship to type of anesthetic, and type of obstetrical procedure.2 Most women who died from anesthesia complications were undergoing cesarean section delivery (82%), whereas only about 5% of the deaths were associated with vaginal deliveries. Women who died of complications of general anesthesia (52% of all maternal deaths) primarily died as a result of airway management problems which included aspiration, intubation difficulties, and inadequate ventilation.
In 1985, a unique perspective on anesthesia morbidity and mortality was unveiled with the institution of the American Society of Anesthesiologists Committee on Professional Liability Closed Claims Project. The data from this project are an accumulation of personal damage insurance claims filed against anesthesiologists and subsequently settled.3 Of the nearly 6500 cases in the database, 12% have been associated with obstetrical anesthesia care and nearly three-fourths of these claims have been 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.
Obstetrical airway catastrophes ...