**14. Airway management in obstetric patient during COVID-19 pandemic**

On admission, COVID-19 test should be performed for the obstetric patients. The testing is vital to protect the hospital staff and to prevent the vertical transfer to the neonate [21]. A checklist should be used for pre-anesthesia evaluation. Patients with COVID-19 may be presented with respiratory symptoms including pneumonia, Acute Respiratory Distress Syndrome (ARDS), lung effusion, and hypoxemia. As a physiological arrangement, functional residual capacity (FRC)

reduces in pregnancy. However these pulmonary conditions increase oxygen consumption, deplete the oxygen stores and cause a deeper decrease in FRC. Besides FRC may be lower than closing capacity when the patient lies in supine position for sugery. Therefore effective preoxygenation with left uterus dislocation is required. The operator should take cautions against fluid overload as the patients are sensitive. The delivery or the cesarean section should be performed in an isolation delivery room or negative pressure operating room [22]. Multi-disciplinary based team work isessential with detailed plans. Rapid sequence induction is recommended. A clamp is also recommended during the preparation period. Following tracheal intubation, lung-protective strategies should be followed including low tidal volume and PEEP titration. The risk of droplet and aerosol transmission of COVID-19 is a potential problem during mask ventilation and tracheal intubation. Personal protective equipment is recommended [23]. The use of barrier-enclosure devices were used in small case series or small-sample simulation studies. The ability to perform airway manuplations is a major concern for these devices. Therefore there is lack of evidence in this regard [24].

#### **15. Extubation of obstetric patients**

Stimulation of laryngeal reflexes, oxygen depletion, suppression, airway edema, loss of protective reflexes, an increase in sympathetic adrenergic tonus are main problems related with obstetric patients during extubation. Difficult Airway Society recommends awake extubation in patients with associated risk factors [25]. Bailey maneuver, remifentanil technique, staged extubation set, and tube exchange catheters are among advanced techniques [26]. Bailey maneuver is a technique for laryngeal mask exchange. Behind the tracheal tube a supraglottic airway device is inserted. By this way the operator can both ventilate the patient and extubate through the guidance of fiberoptic visualization. Thus, laryngospasm, bleeding, or edema can be treated early. In remifentanil technique, the patient receives low dose remifentanil infusion in order to prevent cough and postoperative pain. Airway exchange catheters are frequently used during extubation. Awake patients can tolerate these aduncts and oxygenation is possible. If reintubation is indicated the operator can advance the tracheal tube.

#### **16. Postoperative monitoring**

Awake extubation should be preferred. Muscle relaxant agents should be reversed. Sugammadex is recommended in cases with rocuronium. The patient can deteriorate and the airway may become obstructed. Therefore monitoring and supervision by experienced personnel are essential. A backup plan should be created and the team should be ready for reintubation. Ventilation, oxygen and carbon dioxide levels should be monitored. Severe preeclampsia, volume overload or existing co-morbidities may complicate the postoperative period.

#### **17. Conclusion**

Pregnant women come to the operating room for non-obstetric surgeries as well as cesarean operations. Pregnancy is characterized by significant physiologic changes in the respiratory system and airway. Reduced functional residual capacity, airway edema, and increased oxygen consumption are main factors. These changes

**189**

**Author details**

Kemal Tolga Saracoglu1

School Istanbul, Turkey

\*, Gul Cakmak<sup>2</sup>

\*Address all correspondence to: saracoglukt@gmail.com

provided the original work is properly cited.

1 Department of Anesthesiology and Intensive Care, Health Sciences University

2 Department of Anesthesiology and Intensive Care, Marmara University Medical

© 2021 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

Kartal Dr. Lutfi Kirdar Training and Research Hospital Istanbul, Turkey

and Ayten Saracoglu<sup>2</sup>

*Airway Management during Pregnancy and Labor DOI: http://dx.doi.org/10.5772/intechopen.96476*

and advanced techniques should be ready.

patients by using low and high flow oxygen delivery systems.

cause airway management to be complicated and difficult. Therefore effective preoxygenation is essential. Besides, apneic oxygenation is recommended in obstetric

Regional anesthesia is preferred over general anesthesia because of its high risk of complications. Guidelines specific to pregnant women have been published and difficult airway management steps should be followed in patients undergoing general anesthesia. Patients with Covid 19 disease may present with Acute Respiratory Distress Syndrome (ARDS), lung effusion, and hypoxemia. Postoperative care should be planned. Extubation of pregnant patients should be considered awake

#### *Airway Management during Pregnancy and Labor DOI: http://dx.doi.org/10.5772/intechopen.96476*

*Special Considerations in Human Airway Management*

there is lack of evidence in this regard [24].

**15. Extubation of obstetric patients**

operator can advance the tracheal tube.

**16. Postoperative monitoring**

reduces in pregnancy. However these pulmonary conditions increase oxygen consumption, deplete the oxygen stores and cause a deeper decrease in FRC. Besides FRC may be lower than closing capacity when the patient lies in supine position for sugery. Therefore effective preoxygenation with left uterus dislocation is required. The operator should take cautions against fluid overload as the patients are sensitive. The delivery or the cesarean section should be performed in an isolation delivery room or negative pressure operating room [22]. Multi-disciplinary based team work isessential with detailed plans. Rapid sequence induction is recommended. A clamp is also recommended during the preparation period. Following tracheal intubation, lung-protective strategies should be followed including low tidal volume and PEEP titration. The risk of droplet and aerosol transmission of COVID-19 is a potential problem during mask ventilation and tracheal intubation. Personal protective equipment is recommended [23]. The use of barrier-enclosure devices were used in small case series or small-sample simulation studies. The ability to perform airway manuplations is a major concern for these devices. Therefore

Stimulation of laryngeal reflexes, oxygen depletion, suppression, airway edema, loss of protective reflexes, an increase in sympathetic adrenergic tonus are main problems related with obstetric patients during extubation. Difficult Airway Society recommends awake extubation in patients with associated risk factors [25]. Bailey maneuver, remifentanil technique, staged extubation set, and tube exchange catheters are among advanced techniques [26]. Bailey maneuver is a technique for laryngeal mask exchange. Behind the tracheal tube a supraglottic airway device is inserted. By this way the operator can both ventilate the patient and extubate through the guidance of fiberoptic visualization. Thus, laryngospasm, bleeding, or edema can be treated early. In remifentanil technique, the patient receives low dose remifentanil infusion in order to prevent cough and postoperative pain. Airway exchange catheters are frequently used during extubation. Awake patients can tolerate these aduncts and oxygenation is possible. If reintubation is indicated the

Awake extubation should be preferred. Muscle relaxant agents should be reversed. Sugammadex is recommended in cases with rocuronium. The patient can deteriorate and the airway may become obstructed. Therefore monitoring and supervision by experienced personnel are essential. A backup plan should be created and the team should be ready for reintubation. Ventilation, oxygen and carbon dioxide levels should be monitored. Severe preeclampsia, volume overload

Pregnant women come to the operating room for non-obstetric surgeries as well as cesarean operations. Pregnancy is characterized by significant physiologic changes in the respiratory system and airway. Reduced functional residual capacity, airway edema, and increased oxygen consumption are main factors. These changes

or existing co-morbidities may complicate the postoperative period.

**188**

**17. Conclusion**

cause airway management to be complicated and difficult. Therefore effective preoxygenation is essential. Besides, apneic oxygenation is recommended in obstetric patients by using low and high flow oxygen delivery systems.

Regional anesthesia is preferred over general anesthesia because of its high risk of complications. Guidelines specific to pregnant women have been published and difficult airway management steps should be followed in patients undergoing general anesthesia. Patients with Covid 19 disease may present with Acute Respiratory Distress Syndrome (ARDS), lung effusion, and hypoxemia. Postoperative care should be planned. Extubation of pregnant patients should be considered awake and advanced techniques should be ready.
