Society for Obstetric Anesthesia and Perinatology
Section Editor: Cynthia A. Wong
FOCUSED REVIEW
CME
The Unanticipated Difficult Intubation in Obstetrics
Jill M. Mhyre, MD, and David Healy, MD
In this focused review, we discuss an algorithm specifically for the unanticipated difficult
intubation in obstetrics. This generic algorithm emphasizes a standardized and prespecified
sequence of interventions to provide safe, efficient, and effective airway management for the
emergency obstetric surgical patient. Individual institutions and anesthesia providers are encour-
aged to use this framework to select specific pieces of equipment for each step, and to create regular
opportunities for all obstetric anesthesia providers to become facile with each airway device and to
integrate the algorithm under simulated conditions. (Anesth Analg 2011;112:648–52)
A pproximately 1 in 300 obstetric patients who un-
dergo the induction of general anesthesia will have
a failed intubation with standard direct laryngos-
copy.1–3 The most effective strategy to manage the difficult
airway in obstetrics is to avoid it. However, once rapid
sequence induction of general anesthesia is selected, the
anesthesiologist should have a preformulated strategy to
manage the unanticipated difficult intubation.4 Although
comprehensive difficult airway algorithms are available,5,6
a well-rehearsed algorithm specific for the obstetric patient
may be more useful in this setting.7–12 Figure 1 is a
suggested algorithm that synthesizes existing documents in
a concise format. This focused review expands on the
algorithm and discusses the rationale behind it.
Before the anesthetic induction, practitioners should
consider aspiration prophylaxis and optimize patient and
table position, oxygen administration, operator, medication
dosing, and equipment. For most women, particularly
those who are obese, the optimal position is ramped with
left uterine displacement. The ideal ramp aligns the exter-
nal auditory meatus with the xiphoid process in a horizon-
tal plane.13 Optimal oxygenation is essential to achieve the
longest possible duration of apnea before desaturation, and
requires 3 to 5 minutes of tidal volume breathing with 100%
oxygen14 or 8 deep breaths over 60 seconds.14 –16 Equip-
ment should be immediately available for the entire airway
management algorithm. Table 1 presents a suggested list of
basic equipment that should be prepared on the work
surface of the anesthesia machine before inducing any
obstetric anesthetic. Remaining equipment should be
stored in a portable storage unit located in the obstetric
operative suite.4
From the Department of Anesthesiology, The University of Michigan Health
System, Ann Arbor, Michigan.
Accepted for publication November 24, 2010.
Supported by the Department of Anesthesiology, The University of Michi-
gan Health System, Ann Arbor, MI.
The authors declare no conflicts of interest.
Address correspondence and reprint requests to Jill M. Mhyre, MD, Depart-
ment of Anesthesiology, The University of Michigan Health System, L3622
Women’s Hospital, 1500 E. Medical Center Dr., SPC 5278, Ann Arbor, MI
48109-5278. Address e-mail to jmmhyre@umich.edu.
Copyright © 2011 International Anesthesia Research Society
DOI: 10.1213/ANE.0b013e31820a91a6
648 www.anesthesia-analgesia.org
The anesthetic induction drug should be selected based
on availability and overall clinical condition of the patient.
Succinylcholine provides better intubating conditions more
rapidly than rocuronium, with an average recovery time of
⬍10 minutes.17 Gentle mask ventilation before laryngos-
copy may be considered in fasted patients.18 To maximize
oxygenation and minimize gastric insufflation, any attempt
at ventilation should be an optimized attempt, character-
ized by oral airway insertion, jaw thrust, cricoid pressure
adjustment, and a well-fitting facemask.
For the first intubation attempt, priorities include speed, a
high rate of success, and minimal airway trauma. Standard
direct laryngoscopy to insert a styletted small-diameter endotra-
cheal tube remains the gold standard for tracheal intubation in
obstetrics. Cricoid pressure is controversial and discussion of its
use is beyond the scope of this review. However, cricoid pressure
should be reduced, adjusted (BURP: backward, upward, right-
ward pressure), or released if necessary to facilitate intuba-
tion or ventilation.19 –21 Success rates for each intubation
attempt may be further improved by gum elastic bougie
insertion, a smaller-diameter endotracheal tube, and minor
head position adjustments.
If intubation fails, mask ventilation is recommended to
oxygenate the patient, assess the ease of ventilation, and
provide time to set up equipment for the second intubation
strategy.15,16,18 A 2-handed technique may improve gas
exchange if mask ventilation is difficult. For patients who
remain well oxygenated, it may be appropriate to move
immediately to the second intubation attempt.
The backup intubation strategy should include familiar
equipment, with options listed in Table 2. The specific
strategy is less important than expertise in deploying it.
Videolaryngoscopy is becoming the rescue strategy of
choice, and some authors even advocate it as the primary
laryngoscopic technique. However, at this time, compara-
tive studies among obstetric patients are not available.
Three small series describe obstetric airway management
with an Airtraq22,23 or a GlideScope.24 Comparative studies
among non-obstetric patients with predicted difficult intu-
bation do not favor any particular videolaryngoscope,25 but
speed, simplicity, reliability, and efficiency are desirable
characteristics.
March 2011 • Volume 112 • Number 3
Unanticipated Difficult Intubation in Obstetrics
Figure 1. Suggested algorithm. *Adjust cricoid pressure; backward, upward, rightward pressure (BURP); bougie; minor position adjustments.
†Oral airway, jaw thrust, adjust cricoid pressure, 2-handed technique.
Table 1. Suggested Airway Equipment to Maintain
for the Induction of Obstetric Anesthesia
Facemask and oral airways
Gauze and a tongue blade
2 working laryngoscope handles
Macintosh blades: sizes 3 and 4
6.5 styletted endotracheal tube with an empty 10-mL syringe connected
to the pilot balloon
Backup endotracheal tubes in a range of sizes
Gum elastic bougie
Primary extraglottic airway appropriate for a 70- to 100-kg person (Table 3)
Suction adequate to remove secretions
Although each potential device might be optimal under
select circumstances, the obstetric patient with failed intu-
bation will be served best by clarity of purpose and action.
Therefore, the institutional algorithm should select specific
March 2011 • Volume 112 • Number 3
techniques and equipment for each step of the general
algorithm.26 Each institution should establish a program by
which all personnel responsible for obstetric patients be-
come facile with each airway device, and are able to
integrate the series of techniques into the difficult airway
algorithm.26,27 The true cost of each device will include not
only the cost of use for each emergency, but also the cost of
training all providers to a level of proficiency, and main-
taining the equipment in an ongoing state of readiness. An
effective device may be considered cost saving if it avoids
the medical, legal, and emotional consequences of just one
failed airway.
Help should be requested as soon as difficulty is antici-
pated or encountered. The response will depend on insti-
tutional resources. At a minimum, the institutional difficult
airway algorithm should specify the appropriate respond-
ers and an efficient means to contact them.
www.anesthesia-analgesia.org 649
 FOCUSED REVIEW

Table 2. Options for Secondary Table 3. Selected Options for

Intubation Equipment Extraglottic Airways
Manufacturer Manufacturer
Direct laryngoscopes Supraglottic airways with an
McCoy blade esophageal drain
Miller blade inserted by a LMA ProSeal™ LMA North America, San Diego, CA
paramolar approach LMA Supreme™ LMA North America, San Diego, CA
Intubation guides i-gel姞 Intersurgical Ltd., Wokingham, UK
LMA FasTrach™ ⫾ LMA North America, San Diego, CA Supraglottic airways designed
fiberoptic bronchoscope to facilitate intubation
Air-Q™ ⫾ fiberoptic Cookgas, St. Louis, MO Air-QTM Cookgas, St. Louis, MO
bronchoscope LMA FasTrach™ LMA North America, San Diego, CA
Lighted stylet Supraglottic airway without an
Videolaryngoscopes esophageal drain
C-Mac姞 Karl Storz, Tuttlingen, Germany Classic LMA™, LMA Unique™ LMA North America, San Diego, CA
GlideScope姞 Verathon Medical, Bothell, WA SLIPA™ (50-mL esophageal SLIPA Medical Ltd., Douglas, Isle
Airtraq姞 Prodol Ltd., Vizcaya, Spain reservoir) of Man, UK
Pentax-AWS™ Hoya Corp., Tokyo, Japan Retroglottic airways with an
Truview EVO2™ Truphatek Holdings Ltd., Netanya, esophageal balloon and an
Israel esophageal drain
McGRATH姞 Series5 Aircraft Medical, Edinburgh, UK Laryngeal Tube VBM Medizintechnik, Sulz,
McGRATH姞 MAC Aircraft Medical, Edinburgh, UK (LTS姞, LTS-D™) Germany
Coopdech姞 C-Scope Daiken Medical Co., Osaka, Japan EasyTube姞 Rüsch, a Teleflex Medical
Optical stylets Company, Durham, NC
Bonfils™ Karl Storz, Tuttlingen, Germany Combitube姞 Covidien-Nellcor, Boulder, CO
Levitan™ Clarus Medical, Minneapolis, MN
Shikani SOS™ Clarus Medical, Minneapolis, MN
Video System™ (CVS) Clarus Medical, Minneapolis, MN
Video RIFL姞 AI Medical Devices, Inc.,
Williamston, MI cesarean delivery patients managed under general anesthe-
sia.43 LMA insertion was successful on the first attempt in
98% of patients and effective within 3 attempts for all but 7
patients, with no cases of regurgitation or aspiration in the
Oxygenation and ventilation take priority over intubation entire series. Cricoid pressure release is recommended to
when the hemoglobin saturation decreases below 90%, cya- facilitate extraglottic airway insertion, and may be reap-
nosis develops, or after 2 intubation attempts fail. Each plied once adequate ventilation is established.43– 45
attempt entails one insertion of the relevant airway equip- To avoid aspiration with an extraglottic airway, it is
ment by a single provider, and should be completed in ⬍1 necessary to ensure proper siting of the device, select a
minute. A review of the American Society of Anesthesiologists device with an esophageal drain or an esophageal balloon
obstetric closed claims data suggests that repeated attempts at or both, maintain cricoid pressure as ventilation permits
intubation may result in progressive difficulty in ventilation that (releasing and reapplying briefly during insertion), ask the
ultimately leads to complete airway obstruction.28 surgeons to limit fundal pressure during delivery, and
If intubation fails, then positive pressure ventilation maintain adequate anesthesia. Intraoperative coughing can
with either a facemask or an extraglottic airway may be precipitate regurgitation and dislodge the device.46 In the
used to await, and then support, spontaneous ventilation. event of regurgitation with an extraglottic airway, experts
Once adequate ventilation is established, the decision to recommend positioning the patient head down and on her
proceed with surgery or awaken the patient weighs the side if possible, leaving the airway in place, suctioning the
risks of maternal aspiration and subsequent failed ventila- esophageal drain, inserting an orogastric tube to empty the
tion against the maternal and fetal consequences of delayed stomach contents, and consideration of fiberoptic intuba-
delivery. tion and bronchoscopy.46
Extraglottic airway options are listed in Table 3. The For emergent cesarean delivery with an unsecured air-
most important characteristic of an extraglottic airway used way, it is probably best to wait until the neonate has been
for airway rescue is rapid, reliable insertion. An esophageal delivered to consider additional attempts at definitive
drain, high sealing pressure, and features that facilitate airway management. Even after delivery, if ventilation is
intubation are desirable. Several case reports document adequate and the surgery is straightforward, attempts at
successful airway protection in the setting of copious intubation or surgical airway access may carry more risks
gastric contents removed through an esophageal drain.29 –32 than benefits. If intubation is essential, then an optical
Retropharyngeal tube airways, such as the Laryngeal Tube, guidance technique may help to limit further airway
have a relatively narrow profile, and may be preferred in trauma with repeated blind attempts.
the setting of significant oropharyngeal edema.12,33 If ventilation becomes impossible at any point, then
A number of case reports and small series have described the patient’s neck and head should be repositioned, and
successful obstetric airway rescue with a Classic laryngeal equipment prepared for a surgical airway. In the case of
mask airway (LMA),2,34 –36 ProSeal LMA,2,35,37– 40 LMA Fas- impossible mask ventilation, a single attempt to insert an
Trach,2,41 Combitube,42 and Laryngeal Tube-S.31 The Classic extraglottic airway could be completed while an assistant
LMA has been used electively in a series of 1067 scheduled prepares equipment for needle or cannula cricothyrotomy.

650 www.anesthesia-analgesia.org ANESTHESIA & ANALGESIA

Unanticipated Difficult Intubation in Obstetrics
Further noninvasive airway management should be com-
pleted by a second provider while the surgical airway is
secured without delay.10,47
Multiple invasive airway techniques have been com-
pared with varying results and are beyond the scope of this
review. All invasive airway techniques may introduce
morbidity; frequent training is thought to facilitate effi-
ciency, effectiveness, and safety. Proficiency with the
Melker percutaneous cricothyrotomy dilational set (Cook
Medical Inc., Bloomington, IN) may require as few as 5
insertion simulations48; however, performance seems to
decline within 3 months, and frequent retraining is neces-
sary.a Regardless, review of closed claims data for injuries
attributed to invasive airway access suggests that the most
serious complication of any emergent invasive airway
technique is a failure to apply the technique early enough,
before the consequences of significant hypoxia develop.49
Failed oxygenation resulting in maternal cardiac arrest
in a patient ⬎20 weeks’ gestational age mandates perimor-
tem cesarean delivery within 5 minutes of the arrest to
optimize the effectiveness of chest compressions for mater-
nal resuscitation.50,51
General anesthesia continues to have an essential role in
obstetrics whenever neuraxial anesthesia is contraindicated or
fails, or surgical urgency demands it. Usually, airway man-
agement is uneventful, but unanticipated difficult intubations
do continue to occur. To prepare, anesthesiologists should
select and verify appropriate airway equipment, establish
reliable systems for equipment maintenance, and ensure
comprehensive training in the use of these devices according
to a succinct airway algorithm.
DISCLOSURES
Name: Jill M. Mhyre, MD.
Role: This author helped review the literature and write the
manuscript.
Attestation: Jill M. Mhyre approved the final manuscript.
Name: David Healy, MD.
Role: This author helped review the literature and write the
manuscript.
Attestation: David Healy approved the final manuscript.
ACKNOWLEDGMENTS
The authors acknowledge with appreciation Mary Lou Green-
field, MPH, MS, Lauren Cook, and Syed Shabbir for their work
on this project.
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