Is there anything more scary than a difficult intubation in a patient undergoing emergency Caesarian delivery? The subject was discussed by Conan McCaul at the Western Anaesthesia Symposium.

The vast majority of women in the 3rd trimester have a Mallampati score of 3 or 4. The MP grade may actually become worse during the course of labour!

Predictive tests are for Macintosh intubation – they tell us nothing about LMA, fiber optics and rescue airways. The no1. risk factor is MP4, then short neck, receding mandible and then protruding incisors and MP3. But none of these alone are great predictors – MP4 only predicts difficult airway in 4%.

The published incidence of difficult airway is 4.2% (1.8 – 6%). Failed intubations – junior doctors, out of hours and may be related to inexperience rather than bad anatomy.

In the Brigham and Women’s hospital – over 5 years there were only 100 GAs for CS and 1 in 50,000 failed intubations. CMACE 2006-8 – 1 failed ETT resulting in death (the patient had a working epidural in situ).

In reality – there are very few intubations in obstetrics now; very few difficult intubations are encountered.

Every hospital should have a failed intubation protocol that includes supraglottic airways.

The major way of reducing failed intubation is to improve the system  – obstetricians flagging high risk patients are appropriate classification of C-sections. Prophylactic epidural

CS should be categorized. For example – Cat 1 – sustained fetal brady, hemorrhage.

In utero resuscitation: oxytocin off, full left lateral position, iv fluid, tocolysis.

“Patients do not die from failure to intubate – they die from failure to stop trying to intubate”.