Skip to main content

Advertisement

SpringerLink
Log in

Respiratory and Airway Considerations in Obstetric Patients

  • Obstetric Anesthesia (LR Leffert, Section Editor)
  • Published:
Current Anesthesiology Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

The purpose of this article is to provide the current evidences on respiratory and airway medicine in the obstetric population.

Recent Findings

The prevalence of obstructive sleep apnea (OSA) among pregnant women is increasing. Upper body elevation improves respiratory mechanics in parturients and reduces the risk of postpartum OSA. Clinically significant respiratory depression from neuraxial opioid administration, compared to parenteral, is extremely rare.

The incidence of failed tracheal intubation in obstetric patients is higher than that in non-obstetric patients and it has been unchanged recently. The first obstetric-specific guidelines for the management of difficult airway were published in 2015.

The incidence of serious aspiration in obstetric patients is low and has been decreasing. Interventions to reduce aspiration at cesarean delivery recommended by recently published guidelines and clinical studies will be discussed. Supplemental oxygen during uncomplicated delivery, either cesarean or vaginal, has been controversial.

Summary

Understanding the changes in airway anatomy and respiratory physiology related to pregnancy, and adherence to evidence-based guidelines are essential in taking care of obstetric patients. Recently published scholarly articles and clinical guidelines relevant to respiratory physiology and airway management in obstetric anesthesia will be presented.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Lewis G. Why Mothers Die 2000-2002: The sixth report of confidential enquiries into maternal deaths in the United Kingdom. ROCG. 2004;2004:338.

    Google Scholar 

  2. Knight M, Bunch K, Tuffnell D, Jayakody H, Shakespeare J, Kotnis R, Kenyon S, Kurinczuk JJ (Eds.) on behalf of MBRRACE-UK. Saving lives, improving mothers’ care - lessons learned to inform maternity care from the UK and Ireland confidential enquiries into maternal deaths and morbidity 2014–16. Oxford: National Perinatal Epidemiology Unit, University of Oxford 2018.

  3. Pilkington S, Carli F, Dakin MJ, Romney M, De Witt KA, Doré CJ, et al. Increase in Mallampati score during pregnancy. Br J Anaesth. 1995;74(6):638–42.

    CAS  PubMed  Google Scholar 

  4. Leboulanger N, Louvet N, Rigouzzo A, de Mesmay M, Louis B, Farrugia M, et al. Pregnancy is associated with a decrease in pharyngeal but not tracheal or laryngeal cross-sectional area: a pilot study using the acoustic reflection method. Int J Obstet Anesth. 2014;23(1):35–9.

    CAS  PubMed  Google Scholar 

  5. Kodali BS, Chandrasekhar S, Bulich LN, Topulos GP, Datta S. Airway changes during labor and delivery. Anesthesiology. 2008;108(3):357–62.

    PubMed  Google Scholar 

  6. Pien GW, Pack AI, Jackson N, Maislin G, Macones GA, Schwab RJ. Risk factors for sleep-disordered breathing in pregnancy. Thorax. 2014;69:371–7.

    PubMed  Google Scholar 

  7. Zaremba S, Mueller N, Heisig AM, Shin CH, Jung S, Leffert LR, et al. Elevated upper body position improves pregnancy-related OSA without impairing sleep quality or sleep architecture early after delivery. Chest. 2015;148(4):936–44.

    PubMed  Google Scholar 

  8. Antony KM, Agrawal A, Arndt ME, Murphy AM, Alapat PM, Guntupalli KK, et al. Obstructive sleep apnea in pregnancy: reliability of prevalence and prediction estimates. J Perinatol. 2014;34:587–93.

    CAS  PubMed  PubMed Central  Google Scholar 

  9. Louis JM, Mogos MF, Salemi JL, Redline S, Salihu HM. Obstructive sleep apnea and severe maternal-infant morbidity/mortality in the United States, 1998-2009. Sleep. 2014;37:843–9.

    PubMed  PubMed Central  Google Scholar 

  10. Mhyre JM, Riesner MN, Polley LS, Naughton NN. A series of anesthesia related maternal deaths in Michigan, 1985-2003. Anesthesiology. 2007;106:1096–104.

    PubMed  Google Scholar 

  11. Creanga AA, Berg CJ, Syverson C, Seed K, Bruce FC, Callaghan WM. Pregnancy-related mortality in the United States, 2006-2010. Obstet Gynecol. 2015;125:5–12.

    PubMed  Google Scholar 

  12. Callaghan WM. Overview of maternal mortality in the United States. Semin Perinatol. 2012;36:2–6.

    PubMed  Google Scholar 

  13. Hignett R, Fernando R, McGlennan A, McDonald S, Stewart A, Columb M, et al. A randomized crossover study to determine the effect of a 30 degrees head-up versus a supine position on the functional residual capacity of term parturients. Anesth Analg. 2011;113:1098–102.

    PubMed  Google Scholar 

  14. • American Society of Anesthesiologists Task Force on Perioperative Management of patients with obstructive sleep a. Practice guidelines for the perioperative management of patients with obstructive sleep apnea: an updated report by the American Society of Anesthesiologists Task Force on perioperative management of patients with obstructive sleep apnea. Anesthesiology. 2014;120:268–86 The American Society of Anesthesiologists Guideline on perioperative management of patients with OSA.

    Google Scholar 

  15. Aiono-Le Tagaloa L, Butwick AJ, Carvalho B. A survey of perioperative and postoperative anesthetic practices for cesarean delivery. Anesthesiol Res Pract. 2009;2009:510642.

    PubMed  Google Scholar 

  16. Carvalo B. Respiratory depression after neuraxial opioids in the obstetric setting. Anesth Analg. 2008;107(3):956–61.

    Google Scholar 

  17. Lee LA, Caplan RA, Stephens LS, Posner KL, Terman GW, Voepel-Lewis T, et al. Postoperative opioid-induced respiratory depression: a closed claims analysis. Anesthesiology. 2015;122(3):659–65.

    CAS  PubMed  Google Scholar 

  18. Ko S, Goldstein DH, VanDenKerkhof EG. Definitions of “respiratory depression” with intrathecal morphine postoperative analgesia: a review of the literature. Can J Anaesth. 2003;50:679–88.

    PubMed  Google Scholar 

  19. Crowgey TR, Dominguez JE, Peterson-Layne C, Allen TK, Muir HA, Habib AS. A retrospective assessment of the incidence of respiratory depression after neuraxial morphine administration for postcesarean delivery analgesia. Anesth Analg. 2013;117(6):1368–70.

    CAS  PubMed  Google Scholar 

  20. • Sharawi N, Carvalho B, Habib AS, Blake L, Mhyre JM, Sultan PA. Systematic review evaluating neuraxial morphine and diamorphine-associated respiratory depression after cesarean delivery. Anesth Analg. 2018;127(6):1385–95 A review of articles examining the prevalence of neuraxial opioid-induced respiratory depression.

    CAS  PubMed  Google Scholar 

  21. • American Society of Anesthesiologists Task Force on Neuraxial Opioids, Horlocker TT, Burton AW, Connis RT, Hughes SC, Nickinovich DG, et al. Practice guidelines for the prevention, detection, and management of respiratory depression associated with neuraxial opioid administration. Anesthesiology. 2009;110(2):218–30 The American Society of Anesthesiologists Guidelines on Respiratory Depression Associated with Neuraxial Opioid Administration.

    Google Scholar 

  22. Chiron B, Laffon M, Ferrandiere M, Pittet JF, Marret H, Mercier C. Standard preoxygenation technique versus two rapid techniques in pregnant patients. Int J Obstet Anesth. 2004;13(1):11–4.

    CAS  PubMed  Google Scholar 

  23. Rapaport S, Joannes-Boyau O, Bazin R, Janvier G. Comparison of eight deep breaths and tidal volume breathing preoxygenation techniques in morbid obese patients. Ann Fr Anesth Reanim. 2004;23(12):1155–9.

    CAS  PubMed  Google Scholar 

  24. •• Kinsella SM, Winton AL, Mushambi MC, Ramaswamy K, Swales H, Quinn AC, et al. Failed tracheal intubation during obstetric general anaesthesia: a literature review. Int J Obstet Anesth. 2015;24(4):356–74 A review of the literature on obstetric failed tracheal intubation from 1970 onwards.

    CAS  PubMed  Google Scholar 

  25. Samsoon GL, Young JR. Difficult tracheal intubation: a retrospective study. Anaesthesia. 1987;42:487–90.

    CAS  PubMed  Google Scholar 

  26. Quinn AC, Milne D, Columb M, Gorton H, Knight M. Failed tracheal intubation in obstetric anaesthesia: 2 yr national case–control study in the UK. Br J Anaesth. 2013;110(1):74–80.

    CAS  PubMed  Google Scholar 

  27. •• Mushambi MC, Kinsella SM, Popat M, Swales H, Ramaswamy KK, Winton AL, et al. Obstetric Anaesthetists’ Association and Difficult Airway Society guidelines for the management of difficult and failed tracheal intubation in obstetrics. Anaesthesia. 2015;70(11):1286–306 Published in 2015, the first obstetric-specific guidelines for the management of difficult airway, including practical algorithms.

    CAS  PubMed  PubMed Central  Google Scholar 

  28. Frerk C, Mitchell VS, McNarry AF, Mendonca C, Bhagrath R, Patel A, et al. Difficult Airway Society intubation guidelines working group. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth. 2015;115(6):827–48.

    CAS  PubMed  PubMed Central  Google Scholar 

  29. Scott-Brown S, Russell R. Video laryngoscopes and the obstetric airway. Int J Obstet Anesth. 2015;24(2):137–46.

    CAS  PubMed  Google Scholar 

  30. Balki M, Cooke ME, Dunington S, Salman A, Goldszmidt E. Unanticipated difficult airway in obstetric patients: development of a new algorithm for formative assessment in high-fidelity simulation. Anesthesiology. 2012;117(4):883–97.

    PubMed  Google Scholar 

  31. Yao WY, Li SY, Sng BL, Lim Y, Sia AT. The LMA Supreme™ in 700 parturients undergoing cesarean delivery: an observational study. Can J Anaesth. 2012;59(7):648–54.

    PubMed  Google Scholar 

  32. Li SY, Yao WY, Yuan YJ, Tay WS, Han NR, Sultana R, et al. Supreme™ laryngeal mask airway use in general anesthesia for category 2 and 3 cesarean delivery: a prospective cohort study. BMC Anesthesiol. 2017;17:169.

    PubMed  PubMed Central  Google Scholar 

  33. • D'Angelo R, Smiley RM, Riley ET, Segal S. Serious complications related to obstetric anesthesia: the serious complication repository project of the Society for Obstetric Anesthesia and Perinatology. Anesthesiology. 2014;120:1505–12 A report from the serious complication repository project of the Society for Obstetric Anesthesia and Perinatology, an excellent reference for the anesthesia-related complications among obstetric patients.

    CAS  PubMed  Google Scholar 

  34. O'Sullivan G, Liu B, Hart D, Seed P, Shennan A. Effect of food intake during labour on obstetric outcome: randomised controlled trial. BMJ. 2009;338:b784.

    PubMed  PubMed Central  Google Scholar 

  35. • Singata M, Tranmer J, Gyte GM. Restricting oral fluid and food intake during labour. Cochrane Database Syst Rev. 2013 Aug 22;(8):CD003930. A review of the randomized trials examining restriction of oral intake during labour.

  36. •• Practice guidelines for obstetric anesthesia: an updated report by the American Society of Anesthesiologists Task Force on obstetric anesthesia and the Society for Obstetric Anesthesia and Perinatology. Anesthesiology. 2016 Feb;124(2):270-300. Comprehensive guidelines developed by the American Society of Anesthesiologists and the Society for Obstetric Anesthesia and Perinatology on clinical practice in obstetric anesthesia, updated in 2016.

  37. Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: an updated report by the American Society of Anesthesiologists Task Force on preoperative fasting. Anesthesiology. 2011 Mar;114(3):495-511.

  38. Bouvet L, Mazoit JX, Chassard D, Allaouchiche B, Boselli E, Benhamou D. Clinical assessment of the ultrasonographic measurement of antral area for estimating preoperative gastric content and volume. Anesthesiology. 2011;114:1086–92.

    PubMed  Google Scholar 

  39. Arzola C, Perlas A, Siddiqui NT, Carvalho JC. Bedside gastric ultrasonography in term pregnant women before elective cesarean delivery: a prospective cohort study. Anesth Analg. 2015;121(3):752–8.

    PubMed  Google Scholar 

  40. Zieleskiewicz L, Boghossian MC, Delmas AC, Jay L, Bourgoin A, Carcopino X, et al. AzuRea and CAR'Echo collaborative networks. Ultrasonographic measurement of antral area for estimating gastric fluid volume in parturients. Br J Anaesth. 2016;117(2):198–205.

    CAS  PubMed  Google Scholar 

  41. Van de Putte P, Perlas A. Ultrasound assessment of gastric content and volume. Br J Anaesth. 2014;113(1):12–22.

    PubMed  Google Scholar 

  42. McDonnell NJ, Paech MJ, Clavisi OM, Scott KL, ANZCA trials group. Difficult and failed intubation in obstetric anaesthesia: an observational study of airway management and complications associated with general anaesthesia for caesarean section. Int J Obstet Anesth. 2008;17(4):292–7.

    CAS  PubMed  Google Scholar 

  43. • Paranjothy S, Griffiths JD, Broughton HK, Gyte GM, Brown HC, Thomas J. Interventions at caesarean section for reducing the risk of aspiration pneumonitis. Cochrane Database Syst Rev. 2014 Feb 5;(2):CD004943. A review of the randomized trials examining interventions to reduce the risk of aspiration pneumonitis at cesarean section.

  44. • Chatmongkolchart S, Prathep S. Supplemental oxygen for caesarean section during regional anaesthesia. Cochrane Database Syst Rev. 2016;3:CD006161 A review of the randomized trials of low-risk pregnant women undergoing an elective cesarean section under regional anesthesia.

    PubMed  Google Scholar 

  45. Khaw KS, Wang CC, Ngan Kee WD, Pang CP, Rogers MS. Effects of high inspired oxygen fraction during elective caesarean section under spinal anaesthesia on maternal and fetal oxygenation and lipid peroxidation. Br J Anaesth. 2002;88(1):18–23.

    CAS  PubMed  Google Scholar 

  46. Khaw KS, Wang CC, Ngan Kee WD, Tam WH, Ng FF, Critchley LA, et al. Supplementary oxygen for emergency caesarean section under regional anaesthesia. Br J Anaesth. 2009;102(1):90–6.

    CAS  PubMed  Google Scholar 

  47. Khaw KS, Ngan Kee WD, Chu CY, Ng FF, Tam WH, Critchley LA, et al. Effects of different inspired oxygen fractions on lipid peroxidation during general anaesthesia for elective caesarean section. Br J Anaesth. 2010;105(3):355–60.

    CAS  PubMed  Google Scholar 

  48. Hamel MS, Anderson BL, Rouse DJ. Oxygen for intrauterine resuscitation: of unproved benefit and potentially harmful. Am J Obstet Gynecol. 2014;211(2):124–7.

    PubMed  Google Scholar 

  49. • Fawole B, Hofmeyr GJ. Maternal oxygen administration for fetal distress. Cochrane Database Syst Rev. 2012;12:CD000136 A review of the randomized trials of maternal oxygen administration for fetal distress during labor and prophylactic oxygen administration during the second stage of labor.

    PubMed  Google Scholar 

  50. Haydon ML, Gorenberg DM, Nageotte MP, Ghamsary M, Rumney PJ, Patillo C, et al. The effect of maternal oxygen administration on fetal pulse oximetry during labor in fetuses with nonreassuring fetal heart rate patterns. Am J Obstet Gynecol. 2006;195(3):735–8.

    PubMed  Google Scholar 

  51. Garite TJ, Nageotte MP, Parer JT. Should we really avoid giving oxygen to mothers with concerning fetal heart rate patterns? Am J Obstet Gynecol. 2015;212(4):459–60.

    PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Anesthesia, St Luke’s International Hospital, 9-1 Akashicho, Chuo-ku, Tokyo, 104-8560, Japan

    Ayumi Maeda, Nobuko Fujita & Yasuko Nagasaka

Authors
  1. Ayumi Maeda
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Nobuko Fujita
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Yasuko Nagasaka
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Ayumi Maeda.

Ethics declarations

Conflict of Interest

Ayumi Maeda, Nobuko Fujita, and Yasuko Nagasaka declare they have no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This article is part of the Topical Collection on Obstetric Anesthesia

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Maeda, A., Fujita, N. & Nagasaka, Y. Respiratory and Airway Considerations in Obstetric Patients. Curr Anesthesiol Rep 9, 48–54 (2019). https://doi.org/10.1007/s40140-019-00309-0

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s40140-019-00309-0

Keywords

Search

Navigation