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General anaesthetic and airway management practice for obstetric surgery in England: a reply

We thank Drs Dibb and Stallard [1] for their interest in our study [2]. We share their view that the use of videolaryngoscopes in our case series was disappointing. The inequity of provision of videolaryngoscopes on labour wards compared with main operating theatre settings may have contributed to this. The Obstetric Anaesthetists’ Association and Difficult Airway Society guidelines for the management of difficult and failed tracheal intubation in obstetrics recommend that videolaryngoscopes should be immediately available for all obstetric general anaesthetics [3]; addressing this inequity of provision should be a priority formaternity units. Other factors may have also contributed to the limited use observed. Videolaryngoscopy has been extensively studied in many areas of anaesthesia with the notable exception of obstetrics, a group at higher risk of difficulty of failed tracheal intubation. The inherent difficulties of research in obstetric general anaesthesia (small case numbers, unpredictability of cases) likely being the major barrier to rigorous investigation of this tool in the obstetric setting. A Cochrane Review evaluating videolaryngoscopy vs. direct laryngoscopy for adult patients evaluated 64 studies, but only one of these specifically examined obstetric patients [4]. Nevertheless, the small number of studies and case reports in obstetrics, coupled with information from the non-obstetric population, do support the use of videolaryngoscopes in obstetrics. A discussion point around videolaryngoscopy in general, is which device is the most effective in specific contexts. This seems particularly relevant given that over 60% of obstetric general anaesthetics are delivered without direct consultant anaesthetist supervision [2] and that trainees rotate frequently between different hospitals, potentially being required to frequently adapt to new videolaryngoscope devices. This may result in a reluctance to use an unfamiliar videolaryngoscope, or inexperience, contributing to suboptimal device performance. There is clearly a role for regular skills and equipment training in this setting. A final consideration is that there is not, to our knowledge, a videolaryngoscope with a short handle; these are particularly useful in obstetrics where the upward movement of a woman’s breasts when she is supine, can make placement of the laryngoscope handle difficult.