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For decades, the obstetric airway struck fear in the heart of the anesthesiologist as the incidence of failed intubation in obstetrics was reported as 1:250 to 1:300, approximately ten times more frequent than in the general surgical population. In spite of our fancy airway tools, algorithms, and difficult airway workshops, a recently published experience of more than 1,000 obstetric general anesthetics (GA) suggested we had not made progress in this area: the reported incidence of failed intubation was 1:250, and difficult intubation occurred in 3.3% of cases. So, it is with some relief that one reads the article by McKeen et al. in which they report their experience with the maternal airway over a 20-yr period at a Canadian academic tertiary care hospital. In 2,633 GAs, the incidence of failed intubation was 1:1,300, similar to that of the general surgical population, and difficult intubation was encountered in 4.7%, which is at the lower end of the reported range of 1.3% to 16.3% in obstetrics. Does this study refute the widely held belief that intubation is more difficult in the obstetric patient? In other words, do the results reflect the complete picture, or are they a case of ‘‘things are seldom what they seem’’? The reasons for the apparent difficulty in managing the obstetric airway are both clear and unclear. Undoubtedly, there are anatomic and physiologic changes in pregnancy that make the airway of the term pregnant woman more likely to present a less-than-ideal view for intubation. Nevertheless, one would think we would have found solutions to manage the pregnant airway given the many alternatives to direct laryngoscopy, the development of obstetric-specific airway algorithms and associated training drills and efforts to ensure junior trainees are supervised when providing GA. It is our view that there remains more to the story than solely the anatomical and physiological changes to the maternal airway – these factors could be overcome by the use of other airway devices. Other issues, e.g., the environment in which we provide GA in obstetrics, are more dominant and more difficult to tackle. General anesthesia usually is administered for an obstetric emergency, and under these circumstances, the available anesthesia assistance is less skilled, the atmosphere is tense, the time pressure is extreme (unlike anything else we face, other than perhaps a nasty trauma case), and our proclivity is to behave differently than we normally would for anesthesia in a high-risk patient. It is our view that the situational arena is probably the greatest key to our success or failure in managing the airway. Compounding the problem is the fact that the GA rate in obstetrics is only 5% to 7% in most tertiary care academic centres. Consequently, a staff anesthesiologist may perform only five to ten GAs per year on average, resident trainees may perform even fewer, and nursing assistance, relied on by most units, may be turned to for only one GA per year. We have become so expert at providing neuraxial anesthesia that our experience in providing GA in obstetrics has diminished markedly. M. J. Douglas, MD R. L. Preston, MD Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada

The obstetric airway: things are seldom as they seem