OB: Emergent C-Section
Primigravida at 36 weeks with pre-eclampsia and heavy bleeding. Navigate the difficult OB airway and fetal distress logic.
"A 22 y.o. primigravida presents at 36 weeks with 170/100 BP and proteinuria. Now admitted with heavy vaginal bleeding and FHR late decelerations. PMH: Allergic to penicillin. PHYS: BP 105/85 (falling); P 111. Mallampati 4 airway."
Hemorrhage management, HELLP syndrome vs pre-eclampsia, and the difficult OB airway.
Defending your choice between neuraxial and General Anesthesia (GA) in a fetal distress scenario with low platelets. OB scenarios appear in nearly 50% of cycles.
How a Board-Certified Consultant answers this scenario.
This is a life-threatening scenario for both mother and fetus. My priority is rapid delivery while maintaining maternal hemodynamics. Given the 105/85 blood pressure and fetal distress, I will not attempt a neuraxial technique which could fail or cause further hypotension.
I will proceed with a Rapid Sequence Induction. I'll utilize a small-diameter ETT (6.0 or 6.5) due to the physiological edema of pregnancy and her Mallampati 4 status, with a video laryngoscope (VL) as my first line. I will use etomidate or a lower dose of propofol with succinylcholine to minimize fetal depression. If intubation fails, I will immediately move to a supraglottic airway or surgical airway to maintain oxygenation, as 'failed intubation, failed ventilation' in OB is a leading cause of maternal mortality.