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MATERNITY SERVICES / Date of issue: 08/08/2012
GUIDELINE TITLE: Obesity in pregnancy, birth and the postnatal period
UNIQUE IDENTIFIER / (Generated by SharePoint)VERSION No / 2
LEAD AUTHOR’S NAME
LEAD AUTHOR’S ROLE & DEPARTMENT / Labour Ward Co-ordinator
CLINICAL DIRECTOR
APPROVAL BODY 1 / Labour Ward Forum
DATE APPROVED: APPROVAL BODY 1 / 11/06/2012
APPROVAL BODY 2 / Women’s Integrated Governance Group
DATE APPROVED: APPROVAL BODY 2 / 07/08/2012
REVIEW DATE / August 2015
LEAD PERSON FOR REVIEW
LOCATION OF COPIES
Named person is responsible for ensuring only current copy is in use. Department managers are responsible for their own areas for ensuring only current copies are in use / Maternity Services Multidisciplinary Guidelines page on Sharepoint
DOCUMENT REVIEW HISTORY
REVIEW DATE / REVIEWED BYDOCUMENT CHECKED FOR
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CORPORATE ISSUES / YesCLINCAL GOVERNANCE ISSUES INCLUDING RISK / Yes
PEOPLE GOVERNANCE ISSUES / Yes
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CONTENTS PAGE
2. Management / 5
3. Implementation and audit / 9
4. Development / 10
5. Glossary of terms / 10
6. References and Bibliography / 10
7. Appendixes / 14
1. Introduction
Obesity is one of the biggest challenges facing maternity services today.
In 2007 it was estimated that 24% of women in the UK age 16 or more were obese (ONS, 2008)
Obesity in the pregnant woman is associated with increased maternal and fetal mortality and morbidity. The CMACE report “Saving Mothers’ Lives” published in 2011 revealed that 49% of the women who died from direct and indirect causes were over-weight or obese and a staggering 78% of the women who died of thromboembolism were also in this category.
Obesity is defined as a BMI (body mass index. kg/m2) of 30 or over at the first antenatal consultation.
CLASSIFICATION OF BODY MASS INDEX
Overweight BMI 25.0 – 29.9
Class I (Obese) BMI 30.0 – 34.9
Class II (Severe obesity) BMI 35.0 – 39.9
Class III (Morbid obesity) BMI >40.0
Super-morbid obesity BMI >50.0
For the purposes of this guideline obesity is defined as a BMI over 35 at booking. However, if the booking BMI is 30-35 with additional risk factors e.g. Maternal age over 35 then referral for consultant care should be considered. If the BMI is above 40 certain additional measures are recommended.
It is important that GP’s, family planning and public health nurses along with obstetricians and midwives are aware of the increased risks of being obese and pregnant and discuss these risks with the women in their care.
RISKS RELATED TO OBESITY IN PREGNANCY
Maternal
1. Spontaneous miscarriage ( Metwally et al, 2007)
2. Thromboembolism ( Larsen et al, 2007)
3. Gestational Diabetes (Sebire et al, 2001)
4. Pre-eclampsia and hypertension ( Callaway et al, 2006)
5. Respiratory problems including asthma and sleep apnoea
6. Infection (Usha et al, 2005)
7. Induction of Labour (Usha et al, 2005)
8. Dysfunctional labour (Usha et al, 2005)
9. Increased risk of Caesarean section (Chu et al, 2007)
10. Difficulties with regional and general anaesthesia (Saravanakumar et al 2006)
11. Post partum haemorrhage (Usha et al, 2005)
12. Wound infection, haematoma and dehiscence (Schneid-Kofman et al, 2005)
13. Failure to start or continue breastfeeding (Amir and Donath, 2007)
14. Maternal death (CEMACE 2011)
Fetal
1. Premature labour (Callaway et al, 2006)
2. Birth defects especially neural tube defects (Rasmussen et al,2008)
3. Heart and facial defects
4. Still birth and neonatal death (Chu et al, 2007)
5. Large for dates (Cedergren, 2004)
6. Childhood obesity(Olson 2009)
Statement of intent
Airedale NHS Foundation Trust fully recognises that the obligation to implement guidance should not override any individual clinician to practice in a particular way if that variation can be fully justified in accordance with Bolam Principles. Such variation in clinical practice might be both reasonable and justified at an individual patient level in line with best professional judgement. In this context, clinical guidelines do not have the force of law. However, the Trust will expect clear documentation of the reasons for such a decision and for this variation. In addition, any decision by an individual patient to refuse treatment in line with best practice must be respected, escalated to the consultant and fully documented in the appropriate records of care/treatment.
2. Management
Service Provision
Pre-conception care
It is important that women are aware of the increased risk of maternal and fetal complications associated with obesity and they should be advised about the possible strategies to minimise them prior to conception.
Women with a BMI of 30 or above should be advised to take 5mg folic acid daily starting at least one month prior to conception and continue to take this increased dose for the first trimester of pregnancy in order to reduce the risk of neural tube defects which are known to be more prevalent among women with obesity.
This group of women may also be offered 10ug Vitamin D daily during pregnancy and breastfeeding to increase serum vitamin D levels.
Other actions include:
· Accurate height and weight measurement and BMI calculation.
· Consider screening for type II diabetes.
· Advice and support to lose weight prior to conception. (NICE 2010)
Antenatal Care
Accurate assessment of weight and BMI is essential in any pregnant woman and should be calculated and documented at first contact and clearly documented in the handheld notes and the electronic patient information system. Those who have a BMI over 35 are classed as high risk pregnancies and require referral for consultant led care and are advised to deliver in hospital. A management plan for the antenatal, intrapartum and postnatal periods should be made and documented in the antenatal notes using the blue form.
Maternal weight should be taken again during the third trimester so as to allow for plans to be made for extra equipment and personnel requirements during labour and delivery.
Antenatal care for all women with a BMI >30 should be maternity team based and include:
(All information to be given by an appropriately trained professional)
· Dietary advice. Advice regarding a healthy eating plan and avoidance of excessive weight gain should be offered in early pregnancy by an appropriately trained professional. This may include referral to a dietician or enrolment in other weight loss programmes. They should be reassured that there is no benefit from further weight gain in pregnancy and no contraindication to weight loss as part of a supervised programme. However, undertaking a rapid weight loss programme is not recommended.
· Weight gain in pregnancy. Whilst there are no formal evidenced based guidelines in the UK on what constitutes a normal weight gain in pregnancy there is guidance available in the USA (Rassmussen et al 2009) which makes recommendations on weight gain targets for different classifications of BMI.
· Advice re risks. If the woman has not had preconception care the information regarding the increased risk of intra partum complications associated with obesity is given in the early ante-natal period. This should be given in a clear but sensitive way to empower the woman to engage with the services available. It is important to inform the woman about the increased level of fetal and maternal monitoring recommended for women with raised BMI. These discussions should be recorded in the maternal notes.
· Thromboprophylaxis. Maternal obesity increases the risk of this in both the antenatal and postnatal period. All women should be constantly assessed throughout pregnancy for the risk of thromboembolism and this risk recorded in the maternal notes with actions taken.
Women with a BMI >30 with 2 other risk factors e.g. age >35, immobility etc. should be considered for prophylactic low molecular weight heparin (LMWH) in the antenatal period.
All pharmacological thromboprophylaxis should be prescribed dose appropriate for maternal weight as per RCOG Clinical Green Top Guideline No 37.(2009)
Mobilisation, correct size TED stockings, hydration and leg exercises should be advised for all women admitted to the ante-natal ward.
Thromboprophyllaxis%20and%20treatment%20of%20thromboembolic%20disease.doc
· Ultrasound scans. These will include:
· A dating scan to determine gestational age. This is important as menstrual irregularities are common in obese women and correct dating will improve the performance of screening tests, also it is sometimes difficult to determine fundal height.
· Obese women should be counselled carefully on the limitations of antenatal ultrasound for detection of fetal abnormalities; this should be reported on the scan report and reiterated by the person reviewing the scan.
· Fundal height measurements may be difficult to assess and scans may be performed as required to exclude significant intrauterine growth restriction. However the scan may indicate a large for dates baby, this should not be used to make decisions about time and mode of delivery. Any decision about induction should be made by the consultant.
· It may be indicated to scan for presentation if in labour or after 37 weeks if presentation cannot be determined by abdominal palpation.
· Glucose Tolerance Test (GTT). Obesity predisposes women to gestational diabetes therefore an assessment should be performed at 28 weeks irrespective of family history on women with a BMI >30 (NICE. CG. 63. 2008) Consideration should be given to repeating the GTT in the third trimester if there are any indicators of gestational diabetes e.g. the baby is large for gestational age, there is excess liquor or any symptoms of diabetes.
· Blood Pressure monitoring should be undertaken only with a correctly sized cuff. The cuff size used should be documented in the notes. Women with a BMI over 35 are at increased risk of hypertension and pre eclampsia, they should have increased surveillance during pregnancy(PRECOG 2004)
· Anaesthetic referral and/or information. All women with a BMI >35 should be given an information sheet outlining the additional problems they may encounter, containing realistic expectations of the success of the different methods of analgesia, in particular the increased failure rates of regional analgesia.
All women with a BMI over 40 should have a face to face antenatal anaesthetic consultation (see anaesthetic referral form) as they are at greater risk of caesarean section and general anaesthesia also venous access may be more difficult. An anaesthetic management plan for labour and delivery should be discussed and documented in the notes. In the case of planned caesarean section an appropriate pre-operative assessment is required which may include an ECG, CXR and echocardiogram.
In addition, women with a BMI less than 40 may need to be seen if they have a particularly challenging body habitus e.g. very short, more distribution of adipose tissue around the pelvis/hips and multiple pregnancies.
· Risk Assessment for delivery for BMI >40 should be undertaken by a midwife in the antenatal clinic about a month prior to the due date. The woman should be weighed again in order to ensure the appropriate mattress, bed, operating table, furniture, TED stockings and manual handling equipment are available or ordered if required. If elective delivery is planned additional staffing levels may be necessary.
· At the completion of the assessment an individualised care plan should be completed including a list of any additional equipment required and documented in the case notes. Tissue viability issues should also be considered and a formal assessment of this risk should be made using the waterlow tool.
Intrapartum Care
Women with a BMI of >35 should be encouraged to deliver on the labour ward in the hospital where a consultant led service and neonatal facilities are available. (NICE.CG.55.2007).
Obesity is not an indication for induction of labour.
When a morbidly obese (BMI >40) patient is admitted in labour:
· Inform senior medical staff when in established labour including senior obstetrician and senior anaesthetist and document in notes. They will then review the notes and assess the woman re plan for labour and identify any potential difficulties. IV access and possible early epidural will be considered. Bloods should be taken for group and save and FBC and Ranitidine 150mg 6 hourly PO prescribed. Clear fluids only in labour. Review progress at regular intervals as dysfunctional labour is more common in obese women
· Midwifery care continuous midwifery care is recommended as there are issues such as pressure areas and fetal monitoring which may be time consuming. Correct size TED stockings and adequate hydration are to be provided. Mobilisation in early labour should be encouraged.
· Fetal monitoring This can be very challenging and continuous monitoring via a fetal scalp electrode (FSE) may be necessary, however this may still be difficult due to vaginal adipose tissue. If a decision is made not to undertake fetal monitoring then a record of the rationale for this along with the discussion with the patient and family should be documented in the notes.
· Logistics The weight limit of the delivery beds is 226kg, but only 68kg for the foot of the bed. Advise the woman and relatives not to sit on the end of the bed at any time.
Delivery
· A senior obstetrician and anaesthetist should be available if required at delivery (RCOG 2009) including attending any operative vaginal or abdominal delivery.
· Shoulder dystocia is more common in obese women and should be anticipated e.g. need for Mc Roberts position.
· Active third stage should be recommended as there is a higher incidence of postpartum haemorrhage in obese women (BMI >30) (CEMACE 2011). A syntocinon infusion may be considered, especially where labour has been prolonged.
· Operating theatre staff should be alerted if any woman with a weight of >120kg or BMI >40 may need an operative intervention in theatre. (The operating table can take a max weight of 300kg.)
· Caesarean section there is an increased risk of wound infection and prophylactic antibiotics should be given IV at the time of surgery. Also women who have more than 2cm subcutaneous fat should have suturing of the subcutaneous tissue space (NICE 2011) to reduce wound infection rate and wound separation.
· Skin to skin. It is important to initiate this early and for a prolonged period if possible as obesity is associated with low breast feeding initiation and maintenance rates.