Airway disasters in obstetric anesthesia

Abstract

Summary The occasional practitioner of obstetric anesthesia may never be in this situation. The full-time practitioner may never be either and, worse, may be ill-suited to managing such an event when it arises. The best ways to avoid this situation or to bail out successfully when it occurs are as follows: 1. Liberal use of regional anesthesia in labor for as many patients as possible, with it being imperative for all patients at high risk of a difficult airway (history, examination), a difficult lumbar puncture (obesity), and a high risk of urgent cesarean section (twins, nonreassuring fetal heart rate trace). 2. Adeptness at lumbar puncture and subarachnoid anesthesia by all those practicing obstetric anesthesia. 3. Communication amongst all professionals in the labor and delivery area. 4. A well-equipped difficult airway cart dedicated to labor and delivery 9 . 5. When trouble occurs, ask for help. Naysayers will point out that regional anesthesia does not guarantee freedom from having to manage the airway. Nevertheless, 300 general anesthetics means 300 airway management opportunities with, on average, one failed intubation, whereas 300 regional anesthetics will result in no more than a few failed or “total spinal” anesthetics and, thus, a much less frequent need to deal with the airway and possibly fail to intubate. The three cornerstones are regional anesthesia, communication, and assistance. Finally, the advisability of full-time obstetric anesthesia practitioners spending some time, on a regular basis, in the general operating room to become familiar with airway management devices will depend on the interests of the individual practitioner, the feelings of other members of the anesthesia department, and the comfort level of the various surgeons and will likely vary from hospital to hospital. It is possible that the next survey of the kind done by Hawkins et al 6 reflecting on an anesthetic practice that includes such rescue devices as the LMA-Fastrach and the Combitube, uncommonly available for most of the period covered by their study (1979–90), will find general anesthesia to be no more lethal on a per case basis than regional anesthesia. One young woman per month, on average, dying from anesthesia in childbirth as reported in that study, is too high a price to pay for the joy of motherhood.