Is general anesthesia for cesarean section (C-section) safer with the use of video laryngoscopes?

Video Laryngoscopy Has Improved Safety of General Anesthesia for Cesarean Section

Videolaryngoscopy should be the first-line intubation device for general anesthesia during cesarean section when a difficult airway is anticipated, as it significantly reduces failed laryngoscopic views and increases first-pass intubation success rates compared to direct laryngoscopy. 1

Evidence for Improved Safety with Videolaryngoscopy

Enhanced Visualization and Success Rates

• In non-obstetric cases, videolaryngoscopy may well replace direct laryngoscopy as the first choice device in patients with predicted difficult intubation, and these considerations should apply equally to obstetric patients 1

• Videolaryngoscopy has been used successfully as both a primary technique and as rescue after failure of other approaches in obstetric cases with anticipated difficult airways 1

• In cases where awake flexible bronchoscopic intubation failed completely, two patients' tracheas were successfully intubated with a videolaryngoscope following induction of general anesthesia 1

Practical Advantages in the Obstetric Setting

• A pragmatic approach combining videolaryngoscopy during rapid sequence induction of general anesthesia with laryngeal mask use after failed tracheal intubation is recommended over attempting to achieve a 15% awake flexible bronchoscopic intubation rate 1

• Awake videolaryngoscopy provides equal success rates and complications but shorter intubation times when compared with fibreoptic bronchoscopy in non-obstetric practice 1

• Videolaryngoscopy is gaining popularity as an awake technique to assess the airway or intubate the trachea in obstetric patients 1

Current Guideline Recommendations

First-Line Use in Anticipated Difficult Airways

• Videolaryngoscopes are now almost universally available in UK obstetric units and have been suggested as the first-line instrument for routine intubation 1

• Videolaryngoscopy is likely to be the preferred intubation technique after induction of general anesthesia in women with a predicted difficult airway 1

• Where possible, videolaryngoscopy should be used for tracheal intubation in patients with suspected or confirmed cervical spine injury, with increased first-pass successful intubation rate especially when spinal immobilization is maintained 1

Integration with High-Flow Nasal Oxygen

• The 2015 OAA/DAS obstetric intubation guidelines advised that high-flow humidified nasal oxygen be considered as a standard technique for procedural oxygenation at induction of general anesthesia, which would be even more applicable for women with a predicted difficult airway 1

• This combination may make videolaryngoscopy after induction of general anesthesia more acceptable than awake techniques in many cases 1

Critical Caveats and Pitfalls

Training Requirements

• Clinicians who perform tracheal intubation in patients with anticipated difficult airways should receive regular training in the use of videolaryngoscopy 1

• The performance of videolaryngoscopes depends on device type, operator expertise, and patient characteristics—ensure adequate training and familiarity with the specific device 2

Technical Considerations

• Videolaryngoscopy may be associated with upper airway or laryngeal trauma particularly when a stylet is used during the procedure—exercise caution when advancing the endotracheal tube 2

• Enhanced laryngeal view does not always guarantee successful tube placement—in one study, endotracheal tube placement failed in 12% of patients despite mostly good laryngeal views 3

• Do not become fixated on the screen; adopt a "patient-screen-patient" approach and observe tube passage as it enters the oral cavity 4

Backup Planning

• Have a backup plan ready, including immediate availability of supraglottic airway devices and surgical airway equipment, in case of failed intubation 2

• If there is a strong likelihood that rescue front-of-neck airway access might be required, perform an ultrasound scan of the neck and mark the cricothyroid membrane before induction 1

Algorithm for Decision-Making

For anticipated difficult airway in cesarean section:

1. First choice: Awake videolaryngoscopy (faster than fiberoptic bronchoscopy, equal success rates) 1

2. Alternative if awake technique declined or time-limited: Videolaryngoscopy after induction with high-flow nasal oxygen 1

3. Rescue after failed videolaryngoscopy: Supraglottic airway device 1

4. Final rescue: Front-of-neck airway access (pre-marked cricothyroid membrane) 1

For unanticipated difficult airway during cesarean section:

• Videolaryngoscopy should be the immediate second-line device if Cormack-Lehane grade III or IV is encountered with direct laryngoscopy 2