A failed intubation occurs in an obese parturient after two attempts. SpO2 is 94% and falling. Ventilation with a bag-mask is adequate. According to the Difficult Airway Society (DAS) Obstetric Airway Guidelines, the NEXT step after declaration of failed intubation (Plan C) with adequate bag-mask ventilation is:
- A Immediate surgical cricothyroidotomy
- B Attempt a third intubation with a different operator using video laryngoscopy
- C Allow the patient to wake up and perform awake fibreoptic intubation
- D Insert a second-generation supraglottic airway device (e.g. ProSeal LMA or i-gel) and proceed if surgery is immediately life-saving ✓
Explanation
DAS 2015 Obstetric Difficult Airway Guidelines (and the 2023 update) stipulate that after failed intubation, if oxygenation is maintained with facemask, the next step is insertion of a second-generation supraglottic airway device (SAD — e.g., i-gel or ProSeal LMA) as Plan C. If oxygenation is maintained via the SAD and the situation is life-threatening (e.g., maternal haemorrhage, fetal bradycardia), surgery may proceed through the SAD. If oxygenation fails with the SAD, this escalates to Plan D: emergency surgical airway (cricothyroidotomy). A third intubation attempt without a new strategy is not recommended (increases trauma and oedema).
Reference: Morgan & Mikhail's Clinical Anesthesiology, 6th ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.