Trainees' experiences of difficult and failed intubation in obstetrics

There is growing concern that the increased use of regional anaesthesia, coupled with shorter training, has reduced opportunities for acquiring experience of airway management in obstetrics [1-3]. In order to find out about trainees' experience of difficult or failed intubation in obstetric patients, we sent a postal questionnaire to the 390 trainee members of the Obstetric Anaesthetists' Association (OAA). Although only 173 completed surveys were returned (a response rate of 44%) and, due to their membership of the OAA, the sample was probably unrepresentative, we would still like to report our results, as there is little information in the field. Seventy-nine percent of respondents had experience of difficult intubation in obstetrics. The most popular piece of equipment to aid intubation was the gum elastic bougie (128 reports), followed by the McCoy laryngoscope (63 reports). The polio blade (30 cases), and short handled laryngoscope (three cases) were less commonly used. Seventy-four percent of respondents had repositioned the head to aid intubation and 46% requested that cricoid pressure be adjusted or released. There were 42 reports of failed intubations. Table 1 shows the initial management and Table 2 the definitive management of the airway in these cases. In the majority of cases a laryngeal mask airway was used to maintain the airway. Interestingly, the Combitube was not mentioned. This probably reflects that, unsurprisingly in the setting of a failed intubation, anaesthetists use equipment that they are more familiar with. There were no reports of cricothyrotomy being resorted to. The subsequent management of the failed intubation was not reported in three cases. Fourteen women were woken prior to proceeding to delivery but in 25 cases the anaesthetist continued with general anaesthesia. Presumably this reflects the fact that in obstetrics, general anaesthesia is used only when there is no other option (for example, extreme urgency or contra-indications to regional anaesthesia). Alternatively, under such stressful conditions, it becomes harder to explore other options than to continue with the original plan. In cases where general anaesthesia was continued, maintaining the airway using a laryngeal mask airway rather than a facemask may reflect current trainees' experience outside obstetrics. In half of the cases in which the laryngeal mask airway was used, cricoid pressure was maintained or re-applied. Also of note are the two cases of awake fibreoptic intubation, which some consider should become an established part of the obstetric anaesthetist's repertoire [4].