**8. Surgical cricothyroidotomy**

The frequency of obesity is increasing in pregnant women. Although regional anesthesia is recommended, surgical intervention may be required under general anesthesia. It is important to identify neck landmarks while performing surgical cricothyroidotomy. Cricothyroidotomy complications vary from 6.1% to 54.5% [9, 10]. Ultrasonography can provide advantages over traditional digital palpation in obese pregnant women by improving the image and increasing the accuracy of cricothyroid membrane identification [11].

#### **9. Difficult airway guide in obstetrics**

The incidence of failed tracheal intubation in obstetric patients is 1/390 [12]. In 2015, the Obstetric Anesthetists' Association and Difficult Airway Society in the UK came together and published the Guideline for difficult intubation in obstetrics [13] (**Figure 1**). Three algorithms are defined according to this guide. These consist of safe obstetric general anesthesia, obstetric failed tracheal intubation, and cannot intubate cannot oxygenate (CICO) steps. The first step is the Pre-induction planning and preparation and planning should be done with a team discussion. RSI is the recommended technique. However, mask ventilation can be performed so that the intraabdominal pressure does not exceed 20 cmH20. The practitioner can attempt at most two times in the presence of difficult tracheal intubation. The third attempt should only be performed by an experienced anesthesiologist. If there is a failure, a failed intubation declaration is made, and help is sought. Continuity of oxygenation is essential. 2 ventilation attempts can be made with a laryngeal mask. Ventilation should be continued with a face mask in case of failure. The 3rd algorithm is initiated if oxygenation fails with the mask. CICO is declared. 100% oxygen is continued to be given. Laryngospasm and insufficient muscle relaxation are excluded. If necessary, neuromuscular blockade is repeated. If oxygenation still fails, the front-of-neck access procedure is applied. If oxygenation of the patient can be achieved before starting the surgical airway, the team should decide according to the clinical condition of the pregnant woman. The patient can be awakened or a decision to continue can be given by evaluating the clinical situation of the pregnant woman and the experience of the operator. Maternal and fetal condition, obesity, surgical factors, aspiration risk, and airway require hazards consideration. Obstetric airway may provide a stressful environment because of failure risk of tracheal intubation and difficult mask ventilation. This may cause a risk of

**Figure 1.**

*Difficult airway society master algorithm for obstetric patients.*

hypoxaemia, and trauma. Besides, team working should be managed carefully and the team leader should overcome possible errors related with decision-making or time management.
