**4. Management**

Management of the obstetric difficult airway requires adequate preoperative preparation, a throughout intraoperative plan, and multiple back-up plans. All practitioners should be familiar with the algorithms for anticipated and unanticipated difficult airway in OB.

### **4.1 Preoperative preparation**

Preoperative preparation should consist of obtaining informed consent, assessing the airway, determining fasting policy, and administering premedication [49]. Prior to obtaining informed consent, the anesthesiologist must provide the patient with comprehensive information regarding the risks and benefits of the GA procedure in the obstetric population. It should also include possible airway management that may be undertaken to address possible airway difficulties during the procedure. Even if airway examination indicates no risk of difficult airway, it risk of unanticipated or unrecognized airway issues and complications is not eliminated. Therefore, the anesthesiologist should always have a management plan for unanticipated airway difficulties even before the general anesthesia is initiated [2, 50].

In addition to increased gastric pressure during pregnancy, prolonged gastric emptying during labor has also been shown to increase the risk of regurgitation and aspiration in laboring women. Therefore, it has been historically recommended to avoid ingesting solid food and clear fluid 6 and before 2 h, respectively, before the operative procedure [51, 52]. As the incidence of maternal death caused by aspiration decreases, more studies are suggesting liberal nil per oral (NPO) guidelines, allowing ingestion of isotonic fluids and light diet during labor [53]. Moreover, several premedication drugs are also used as aspiration prophylaxis. The purpose of these drug is to reduce pH and the amount of gastric volume. The aspiration prophylactic drugs include histamine-2 receptor antagonists (e.g., ranitidine), proton-pump inhibitors (e.g., omeprazole, lansoprazole), nonparticulate antacid (e.g., sodium citrate), or promotility drugs (e.g., metoclopramide) [49, 50, 54, 55]. The use of histamine-2 receptor antagonists with or without a promotility drug is the most common regimen for aspiration prophylaxis in the obstetric patient. Ranitidine and metoclopramide should be administered at least 30 min before induction [56, 57]. In emergent situation, a dose of sodium citrate 30 mL may also be used within 30 min of surgery [56, 58, 59].

In addition to patient preparation, the anesthesiologist should also have a discussion with the team whether to proceed with the procedure or wake the patient in the event of failed tracheal intubation [2, 49]. The Obstetric Anesthetists' Association and Difficult Airway Society (OAA/DAS) provides guidelines for this decision (see **Figure 1**).


#### **Figure 1.**

*Factors to consider in the decision to procced with surgery or wake the patient following failed tracheal intubation. Reproduced from Mushambi et al. [49], with permission from obstetric Anesthetists' association/difficult airway society.*
