All India Difficult Airway Association 2025 guidelines for the management of unanticipated difficult airway in obstetrics under general anaesthesia.

Abstract

Central neuraxial anaesthesia is the preferred approach for caesarean deliveries leading to less frequent use of general anaesthesia. The 2025 guidelines for managing general anaesthesia in obstetrics recommend rapid sequence induction and intubation for parturients requiring general anaesthesia for caesarean delivery. If the initial intubation attempt fails, the team should <i>"Call for help for difficult airway"</i> (Code D) and prioritise oxygenation (SpO₂ > 95%). Tracheal intubation may be attempted by a more experienced operator after re-optimising position and considering alternate airway devices. The primary anaesthesia team can opt for a 2^nd generation supraglottic airway (SGA) device as a rescue device or continue the anaesthetic using a face mask (FM). Maintaining oxygenation is critical. If satisfactory oxygenation is achieved with 2^nd generation SGA or FM, the decision to continue will depend upon maternal and fetal condition. If satisfactory ventilation cannot be maintained with 2^nd generation SGA or FM following failed tracheal intubation, the team declares "complete ventilation failure" and proceeds to surgical cricothyroidotomy. Should maternal cardiac arrest occur, proceed to "resuscitative hysterotomy" to improve chances of saving mother and baby. Post-resuscitation care should continue in the ICU to return the parturient to normalcy. Parturients may have a physiologically difficult airway in addition to anatomical reasons for airway difficulty. Specific steps to deal with associated pathophysiological changes constitute an important aspect of airway management in obstetrics. If a difficult airway is encountered, an "Airway Alert Card" must be given to the parturient and her responsible relatives to avoid similar life-threatening situations in future.