2026 FSA Podium and Poster Abstracts

Introduction / Background: Airway management during labor represents an uncommon but high risk clinical scenario encountered in obstetric anesthesia. Physiologic changes of late pregnancy including progressive upper airway edema, increased vascularity, reduced functional residual capacity, and increased oxygen consumption significantly limit tolerance for apnea and complicate airway instrumentation. Although neuraxial anesthesia is the preferred technique for cesarean delivery, urgent conversion to general anesthesia continues to occur in unpredictable clinical settings. Maternal surveillance programs have consistently identified delayed recognition and escalation during obstetric emergencies as contributors to preventable maternal harm. This review examines contemporary clinical evidence relevant to airway management in laboring patients requiring general anesthesia.

Methods: A narrative review was conducted using PubMed, Embase, and Google Scholar to identify English language, peer reviewed human studies published between 2015 and 2025. Search terms included obstetric anesthesia, pregnancy, labor, airway management, difficult airway, failed intubation, airway edema, oxygenation, and airway assessment. Included studies addressed pregnancy associated airway physiology, epidemiology and predictors of difficult or failed tracheal intubation, airway device performance, oxygenation strategies, and system level interventions applicable to obstetric anesthesia practice. Reference lists of included studies were manually reviewed to identify additional relevant publications.

Results: Across clinical and observational studies, pregnancy associated airway changes were shown to evolve dynamically and may worsen rapidly during labor. Increased airway edema, reduced airway dimensions, and impaired oxygen reserve were consistently associated with obesity, hypertensive disorders of pregnancy, intrapartum fluid administration, and prolonged labor. Unplanned conversion from neuraxial anesthesia to general anesthesia frequently occurred under time pressure, limiting opportunities for airway optimization and contributing to increased risk. In these scenarios, delays in establishing effective ventilation rather than difficulty with tracheal intubation were the predominant contributors to hypoxemia. Traditional bedside airway assessments demonstrated limited sensitivity for predicting difficult airway management and were most informative when repeated as labor progressed. Evidence supports the use of optimized patient positioning and meticulous preoxygenation to reduce hypoxemia during induction of general anesthesia. Video laryngoscopy was associated with improved glottic visualization and higher first attempt tracheal intubation success compared with direct laryngoscopy. When tracheal intubation was delayed or unsuccessful, second generation supraglottic airway devices reliably restored ventilation and oxygenation. Studies evaluating system based interventions identified standardized equipment availability, cognitive aids, simulation based training, and early escalation protocols as factors associated with improved coordination and timely airway rescue during obstetric emergencies.

Discussion / Conclusion: Contemporary evidence supports an airway management approach in labor that emphasizes anticipation of physiologic change, repeated airway assessment, preservation of oxygenation, and early escalation rather than repeated airway instrumentation. Obstetric airway risk is shaped by evolving physiology and clinical urgency, underscoring the importance of preparation and system readiness in anesthesia. Implementation of airway management strategies supported by contemporary clinical data, along with standardized response systems, may improve safety for laboring patients requiring general anesthesia, particularly in urgent and unanticipated clinical scenarios. These findings reinforce the importance of defining airway and oxygenation rescue pathways before induction in laboring patients at risk for urgent conversion to general anesthesia.