Management of an Unanticipated Difficult Airway during Emergency “C” Section—A Novel Approach


Introduction: Knowledge, skill and training in addition to quick thinking, come to the rescue of Anesthesiologists when encountering an unanticipated difficult airway during emergency Caesarean section. Ability to react with time to spare will ensure maternal and fetal well being while handling this life threatening emergency. Case History: While anesthetizing a 22-year parturient for emergency Caesarean section, the endotracheal tube was inadvertently placed in the esophagus. As the call for help was activated, the esophageal tube was delivered thru the endoscopic port of a Patil-Syracuse face mask. After confirming our ability to ventilate the patient without distending the stomach while maintaining the oxygen saturation and end tidal carbon dioxide levels within normal limits, surgery was allowed to proceed under mask anesthesia employing oxygen, nitrous oxide and sevoflurane with rocuronium for muscle relaxation. After a healthy infant was delivered, definitive airway access was obtained with Glidescope? assisted fiberoptic intubation. The esophageal tube was then removed. Further surgery proceeded uneventfully. Discussion: By choosing to deliver the proximal end of the inadvertently placed esophageal tube thru the endoscopic port of a Patil-Syracuse mask and mask ventilating the patient, we have been able to provide that few precious minutes of oxygenation to the distressed fetus before delivery. By isolating and venting the stomach thru the esophageal tube we provided maternal air way protection during the initial phase of the delivery. Definitive airway access was obtained as soon as additional help and equipment were available. Conclusion: Difficult airway algorithm while comprehensive, does not address the question of time management. While dealing with a difficult airway in obstetric anesthesia, time is the single most important factor, which will determine the maternal and fetal well being. We in our case report have attempted to answer that question of “time”.

Share and Cite:

R. Govindarajan, C. Chang, W. Khalil, N. Balogh, E. England and S. Ravikumar, "Management of an Unanticipated Difficult Airway during Emergency “C” Section—A Novel Approach," Surgical Science, Vol. 5 No. 1, 2014, pp. 28-31. doi: 10.4236/ss.2014.51007.

Conflicts of Interest

The authors declare no conflicts of interest.


[1] K. O. Enohumah and C. O. Imarengiae, “Factors Associated with Anesthesia Related Maternal Mortality in a Tertiary Hospital in Nigeria,” Acta Anaesthesiologica Scandinavica, Vol. 50, No. 2, 2006, pp. 206-210.
[2] J. M. R. M. Mhyre and V. Grigorescu, “Anesthesia Related Maternal Mortality in Michigan: 1985-2003,” Anesthesiology, Vol. 104, Supplement 1, 2006, p. A-19.
[3] G. M. Cooper and J. H. McClure, “Maternal Deaths from Anesthesia. An Extract from Why Mothers Die 200-2002,” the Confidential Enquiries into Maternal Deaths in the United Kingdom: Chapter 9: Anesthesia. British Journal of Anaesthesia, Vol. 94, No. 4, 2005, pp. 417-423. 1093/bja/aei066
[4] N. J. McDonnel, M. J. Paech, O. M. Clavisi and K. L. Scott, The ANZCA Trials Group, “Difficult and Failed Intubation in Obstetric Anaesthesia: An Observational Study of Airway Management and Complications Associated with General Anesthesia for Caesarean Section,” International Journal of Obstetric Anesthesia, Vol. 17, No. 4, 2009, pp. 292-297.
[5] R. V. Johnson, G. R. Lyons, R. C. Wilson and A. P. Robinson, “Training in Obstetric General Anesthesia: A Vanishing Art?” Anesthesia, Vol. 55, No. 2, 2000, pp. 179-183. 1046/j.1365-2044.2000.055002179.x
[6] K. N. Williams, F. Carli and R. S. Cormack, “Unexpected, Difficult Laryngoscopy: A Prospective Survey in Routine General Surgery,” British Journal of Anaesthesia, Vol. 66, No. 1, 1991, pp. 38-44.
[7] T. A. King and A. P. Adams, “Failed Tracheal Intubation,” British Journal of Anaesthesia, 1990, Vol. 65, No. 3, pp. 400-414.
[8] J. M. Davies, S. Weeks, L. A. Crone and E. Pavlin, “Difficult Intubation in the Parturient,” Canadian Journal of Anesthesia, Vol. 36, No. 6, 1989, pp. 668-674.
[9] A. Lee, L. T. Fan, T. Gin, M. K. Karmakar and W. D. Nagen Kee, “A Systematic Review (Meta Analysis) of the Accuracy of the Mallampati Tests to Predict the Difficult Airway,” Anesthesia & Analgesia, Vol. 102, No. 6, 2006, pp. 1867-1878.
[10] T. Shiga, Z. Wajima, T. Inove and A. Sakamoto, “Predicting Difficult Intubation in Apparently Normal Patients: A Meta Analysis of Bedside Screening Test Performance,” Anesthesiology, Vol. 103, No. 2, 2005, pp. 429-437.
[11] S. Y. Thong and Y. Lim, “Video and Optic Laryngoscopy Assisted Tracheal Intubation—The New Era,” Anaesthesia and Intensive Care, Vol. 37, No. 2, 2009, pp. 219-233.
[12] K. Aoyama, E. Yasunaga, I. Takenaka, T. Kadoya, T. Sata and A. Shigematsu, “Positive Pressure Ventilation during Fiberoptic Intubation: Comparison of the Laryngeal Mask Airway, Intubating Laryngeal Mask and Endoscopic Mask Techniques,” British Journal of Anaesthesia, Vol. 88, No. 2, 2002, pp. 246-254.
[13] F. Zand and A. Amini, “Use of Laryngeal Tube-S? for Airway Management and Prevention of Aspiration after a Failed Tracheal Intubation in a Parturient,” Anesthesiology, Vol. 102, No. 2, 2005, pp. 481-483.
[14] R. Awan, J. P. Nolan and T. M. Cook, “Use of a Pro-Seal? Laryngeal Mark Airway for Airway Maintenance during Emergency Caesarean Section after Failed Tracheal Intubation,” British Journal of Anaesthesia, Vol. 92, No. 1, 2004,pp. 144-146.
[15] H. Klein, M. Williamson, H. M. Sue-Ling, M. Vucevic and A. C. Quinn, “Esophageal Rupture Associated with the Use of Combitube?,” Anesthesia & Analgesia, Vol. 85, No. 4, 1997, pp. 937-939.
[16] R. S. Greenberg, “Facemask, Nasal and Oral Airway Devices,” Anesthesiology Clinics of North America, Vol. 20, No. 4, 2002, pp. 833-861.
[17] E. A. Djabatey and P. M. Barclay, “Difficult and Failed Intubation in 3430 Obstetric General Anesthetics,” Anaesthesia, Vol. 64, No. 11, 2009, pp. 1168-1171.
[18] G. E. Lewis, “The Confidential Enquiry into Maternal and Child Health (CEMACH). Saving Mother’s Lives; Reviewing Maternal Deaths to Make Motherhood Safer-2003-2005. The Seventh Report on Confidential Enquiries into Maternal Deaths in the United Kingdom,” CEMACH, London, 2007.
[19] C. Keller, J. Brimacombe, M. Boehler, A. Loeckinger and F. Puehringer, “The Influence of Cuff Volume and Anatomical Location on Pharyngeal, Esophageal and Tracheal Mucosal Pressures with the Esophageal Tracheal Combitube,” Anesthesiology, Vol. 96, 2002, pp. 1074-1077.

Copyright © 2023 by authors and Scientific Research Publishing Inc.

Creative Commons License

This work and the related PDF file are licensed under a Creative Commons Attribution 4.0 International License.