Skip to main content Accessibility help
  • Print publication year: 2011
  • Online publication date: December 2011

Chapter 18 - Controversies surrounding airway management and cesarean delivery


Epidurals are the most effective mode of analgesia for labor pain. Neurological complications, although rare, remain one of the most important causes of anxiety in the parturient and it is important to provide reassurance while providing accurate data for informed consent. Central nervous system (CNS) lesions secondary to epidural analgesia are very rare. They can be classified into four etiologies: traumatic, ischemic, infective, or chemical, or can sometimes be a combination thereof. High-quality evidence supports that there is no causal relationship between epidural labor analgesia and the development of new chronic back pain. High-dose epidural fentanyl may be associated with an adverse effect on breastfeeding. Women who labor with epidural analgesia experience an increase in temperature, which is associated with administration of antibiotics to both mother and babies, increased neonatal sepsis workups, as well as possibly increased operative deliveries.

Related content

Powered by UNSILO

Further reading

American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2003; 98: 1269–77.
HendersonJ J, PopalM T, LattoI P & PierceA C. Difficult Airway Society guidelines for management of the unanticipated difficult intubation. Anaesthesia 2004; 59: 675–94.
MhyreJ M & HealyD. Focused review: the unanticipated difficult intubation in obstetrics. Anesth Analg 2011; 112: 648–52.


1. GibbonsL, BelizánJ M, LauerJ Aet al. The Global Numbers and Costs of Additionally Needed and Unnecessary Caesarean Sections Performed per Year: Overuse as a Barrier to Universal Coverage. World Health Report (2010) Background Paper, 30.
2. Ngan KeeW D. Confidential enquiries into maternal deaths: 50 years of closing the loop. Br J Anaesth 2005; 94: 413–16.
3. KinsellaS M. Anaesthetic deaths in the CMACE (Centre for Maternal and Child Enquiries) Saving Mothers’ Lives report 2006–08. Anaesthesia 2011; 66: 243–6.
4. HawkinsJ L, ChangJ, PalmerS Ket al. Anesthesia-related maternal mortality in the United States: 1979–2002. Obstet Gynecol 2011; 117: 69–74.
5. RussellR. Failed intubation in obstetrics: a self-fulfilling prophecy? Int J Obst Anesth 2007; 16: 1–3.
6. TsenL C, PitnerR & CamannW R. General anesthesia for cesarean section at a tertiary care hospital 1990–1995: indications and implications. Int J Obstet Anesth 1998; 7: 147–52.
7. PalanisamyA, MitaniA A & TsenL C. General anesthesia for cesarean delivery at a tertiary care hospital from 2000 to 2005: a retrospective analysis and 10-year update. Int J Obstet Anesth 2011; 20: 10–16.
8. PilkingtonS, CarliF, DakinM Jet al. Increase in Mallampati score during pregnancy. Br J Anaesth 1995; 74: 638–42.
9. FarconE L, KimM H & MarxG F. Changing Mallampati score during labour. Can J Anesth 1994; 41: 50–1.
10. HoodD D & DewanD M. Anesthetic and obstetric outcomes in morbidly obese parturients. Anesthesiology 1993; 79: 1210–18.
11. CollinsJ S, LemmensH J, BrodskyJ Bet al. Laryngoscopy and morbid obesity: a comparison of the “sniff” and “ramped” positions. Obes Surg 2004; 14: 1171–5.
12. MurphyM, HungO, LauncelottGet al. Predicting the difficult laryngoscopic intubation: are we on the right track? Can J Anesth 2005; 52: 231–5.
13. RockeD A, MurrayW B, RoutC C & GouwsE. Relative risk analysis of factors associated with difficult intubation in obstetric anesthesia. Anesthesiology 1992; 77: 67–73.
14. ShigaT, WajimaZ, InoueTet al. Predicting difficult intubation in apparently normal patients. a meta-analysis of bedside screening test performance. Anesthesiology 2005; 103: 429–37.
15. HonarmandM & SafaviR. Prediction of difficult laryngoscopy in obstetric patients scheduled for Caesarean delivery. Eur J Anaesth 2008; 25: 714–20.
16. BasaranogluG, ColumbM & LyonsL. Failure to predict difficult tracheal intubation for emergency caesarean section. Eur J Anaesth 2010; 27: 947–9.
17. YentisS M. Predicting difficult intubation – worthwhile exercise or pointless ritual? Anaesthesia 2002; 57: 105–9.
18. BarnardoP D & JenkinsJ G. Failed tracheal intubation in obstetrics: a 6-year review in a UK region. Anaesthesia 2000; 55: 685–94.
19. RahmanK & JenkinsJ G. Failed tracheal intubation in obstetrics: no more frequent but still managed badly. Anaesthesia 2005; 60: 168–71.
20. HawthorneL, WilsonR, LyonsG & DresnerM. Failed intubation revisited: 17-yr experience in a teaching maternity unit. Br J Anaesth 1996; 76: 680–4.
21. DjabateyE A & BarclayP M. Difficult and failed intubation in 3430 obstetric general anaesthetics. Anaesthesia 2009; 64: 1168–71.
22. ChestnutD H, PolleyL S, TsenL C & WongC A eds. Chesnut’s Obstetric Anesthesia: Principles and Practice, 4th ed. Mosby, 2009.
23. CooperR M. Use of a new videolaryngoscope (GlideScope®) in the management of a difficult airway. Can J Anesth 2003; 50: 611–13.
24. CooperR M, PaceyJ A, BishopM J & McCluskeyS A. Early clinical experience with a new videolaryngoscope (GlideScope) in 728 patients. Can J Anesth 2005; 52: 191–8.
25. SunD A, WarrinerC B, ParsonsD Get al. The GlideScope video laryngoscope: randomized clinical trial in 200 patients. Br J Anaesth 2005; 94: 381–4.
26. JonesP M, TurkstraT P, ArmstrongK Pet al. Effect of stylet angulation and endotracheal tube camber on time to intubation with the GlideScope. Can J Anesth 2007; 54: 21–7.
27. TurkstraT P, ArmstrongP M, JonesP M & QuachT. GlideScope use in the obstetric patient. Int J Obstet Anesth 2010; 19: 123–4.
28. AzizM F, HealyD, KheterpalSet al. Routine clinical practice effectiveness of the GlideScope in difficult airway management: an analysis of 2,004 GlideScope intubations, complications, and failures from two institutions. Anesthesiology 2011; 114: 34–41.
29. MaharajC H, O’CroininD, CurleyGet al. A comparison of tracheal intubation using the Airtraq or the Macintosh laryngoscope in routine airway management: a randomized, controlled clinical trial. Anaesthesia 2006; 61: 1093–9.
30. NdokoS K, AmathieuR, TualLet al. Tracheal intubation of morbidly obese patients: a randomized trial comparing performance of Macintosh and Airtraq laryngoscopes. Br J Anaesth 2008; 100: 263–8.
31. DhonneurG, NdokoS, AmathieuRet al. Tracheal intubation using the Airtraq in morbid obese patients undergoing emergency cesarean delivery. Anesthesiology 2007; 106: 629–30.
32. AmathieuR, CombesX, AbdiWet al. An algorithm for difficult airway management, modified for modern optical devices (Airtraq laryngoscope; LMA C TrachTM): a 2-year prospective validation in patients for elective abdominal, gynecologic, and thyroid surgery. Anesthesiology 2011; 114: 25–33.
33. GrayK, LucasN, RobinsonP Net al. A case series of successful videolaryngoscopic intubations in obstetric patients. Int J Obstet Anesth 2009; 18; Supplement 1: 12.
34. ChadwickI S & VohraA. Anaesthesia for emergency Caesarean section using the Brain laryngeal airway. Anaesthesia 1989; 44: 261–2.
35. McCluneS, ReganM & MooreJ. Laryngeal mask airway for Caesarean section. Anaesthesia 1990; 45: 227–8.
36. VergheseC & BrimacombeJ R. Survey of Laryngeal Mask Airway Usage in 11,910 Patients: Safety and Efficacy for Conventional and Nonconventional Usage. Anesth Analg 1996; 82: 129–33.
37. HanT H, BrimacombeJ, LeeE J & YangH S. The laryngeal mask airway is effective and probably safe in selected healthy parturients for elective Cesarean section. Can J Anesth 2001; 48: 1117–21.
38. KellerC, BrimacombeJ, LirkP & PuhringerF. Failed obstetric tracheal intubation and postoperative respiratory support with the ProSeal laryngeal mask airway. Anesth Analg 2004; 98: 1467–70.
39. HalasehB K, SukkarZ F, HassanL Het al. The use of ProSeal laryngeal mask airway in caesarean section – experience in 3000 cases. Anaesth Intensive Care 2010; 38: 1023–8.
40. TunstallM E. Failed intubation drill. Anaesthesia 1976; 31: 850.
41. HarmerM. Difficult and failed intubation in obstetrics. Int J Obstet Anesth 1997; 6: 25–31.
42. CrosbyE T, CooperR M, DouglasM J, et al. The unanticipated difficult airway with recommendations for management. Can J Anesth 1998; 45: 757–7.
43. VergheseC & RamaswamyB. LMA-Supreme – a new single-use LMA with gastric access: a report on its clinical efficacy. Br J Anaesth 2008; 101: 405–10.
44. SchmidtU & EikermannM. Organizational aspects of difficult airway management: think globally, act locally. Anesthesiology 2011; 114: 3–6.
45. SmithK J, DobranowskiJ, YipGet al. Cricoid pressure displaces the esophagus: an observational study using magnetic resonance imaging. Anesthesiology 2003; 99: 60–4.
46. VannerR. Cricoid pressure. Int J Obstet Anesth 2009; 18: 103–5.
47. PaechM J. “Pregnant women having caesarean delivery under general anaesthesia should have a rapid sequence induction with cricoid pressure and be intubated”. Can this holy cow be sent packing? Anaesth Intensive Care 2010; 38: 989–91.
48. CellenoD, CapognaG, EmanuelliMet al. Which induction drug for cesarean section? A comparison of thiopental sodium, propofol, and midazolam. J Clin Anesth 1993; 5: 284–8.
49. SchreiberJ U, LysakowskiC, Fuchs-BuderT & TramèrM R. Prevention of succinylcholine-induced fasciculation and myalgia: a meta-analysis of randomized trials. Anesthesiology 2005; 103: 877–84.
50. PerryJ J, LeeJ S, SillbergV A & WellsG A. Rocuronium versus succinylcholine for rapid sequence induction intubation. Cochrane Database Syst Rev 2008; 16: CD002788.
51. SharpL M & LevyD M. Rapid sequence induction in obstetrics revisited. Curr Opin Anaesthesiol 2009; 22: 357–61.
52. Nouruzi-SedehP, SchumannM & GroebenH. Laryngoscopy via Macintosh blade versus GlideScope: success rate and time for endotracheal intubation in untrained medical personnel. Anesthesiology 2009; 110: 32–7.