*Difficult Airway in Obstetric Patients DOI: http://dx.doi.org/10.5772/intechopen.108341*

of anesthesia, (2) selection of airway device, (3) maintenance of ventilation, (4) strategy to prevent pulmonary aspiration. To maintain adequate anesthesia, a nonirritant volatile agent such as sevoflurane is commonly used. In the event of uterine atony after delivery, total intravenous anesthesia with propofol may be considered as it has no effect on uterine muscle tone [49]. If a failed intubation has been declared, the anesthesiologist must choose whether to proceed with only a supraglottic airway device or to perform additional tracheal intubation attempts [29]. Although the use of supraglottic airway device is not advisable in elective surgery, its use in caesarian delivery has found to be effective and safe [29, 49, 97]. Again, a second-generation of supraglottic airway device is recommended. If the anesthetist decides to proceed with additional attempt at tracheal intubation, it should be noted that only one attempt by an experienced anesthesiologist with a planned intubation technique should be allowed [29]. The intubation technique must overcome the anatomical constraints that led to the earlier failure. Although the selection of intubation technique depends on anesthesiologist's clinical judgment, it is recommended to use flexible bronchoscope-guided intubation to avoid airway trauma and esophageal intubation [29, 100]. If tracheal intubation fails to be performed safely, a definitive airway with tracheostomy is required [29, 49]. Although controlled ventilation is used in the vast majority of failed intubation cases in the United Kingdom, a case-by-case consideration should be exercised before deciding whether to use spontaneous or controlled ventilation [49, 79]. In addition, to prevent pulmonary aspiration during the procedure, cricoid pressure should be applied until after delivery (**Figures 4** and **5**) [49].

Following failed tracheal intubation, persistent failure to ventilate using facemask and supraglottic airway device leads to a "can't intubate, can't oxygenate" (CICO)

#### **Figure 5.**

*Management of "can't intubate, can't oxygenate" (CICO) in obstetrics. Reproduced from Mushambi et al. [49], with permission from obstetric Anesthetists' association/difficult airway society.*

situation. The CICO situation may be caused by poor chest wall compliance and laryngeal spasm, which can be managed with NMDs [28, 29, 49]. Therefore, once a CICO situation has been identified, apart from calling an ear, nose, and throat surgeon and/or intensivist, it is imperative to rule out laryngeal spasm as the cause of CICO. The reason is to prevent invasive airway management when it can be managed with only NMD [29, 49]. If the succinylcholine has been administered during induction, then a combination of rocuronium and sugammadex is preferred [29, 49, 50]. When laryngospasm has been ruled out as the cause of CICO, front-of-neck procedure should proceed without delay. A front-of-neck procedure refers to procedure to securing airway access via front of the neck by either tracheotomy or cricothyrotomy [29]. Prior to front-of-neck procedure, patient should inhale 100% oxygen via a facemask or supraglottic airway device while waiting for the neuromuscular blockade to be confirmed or established [49]. Once the neuromuscular blockade has been established, front-of-neck procedure can be performed immediately. If an experienced surgeon is present, tracheotomy may be performed to provide definitive airway access [29, 101, 102]. However, cricothyrotomy may be more preferred in emergency setting [29, 50]. If adequate oxygenation is not achieved, a cardiac arrest protocol should be instituted, and undelivered fetus at >20 weeks' gestation age should be delivered via cesarean section immediately [49, 103].
