NHSLA - Maternity Standard 3 Criterion 10

Obesity

OBESITY

NHSLA - Maternity Standard 3 Criterion 10

Aim

Scope / Rationale

Roles And Responsibilities

Process/Procedure

A.The Calculation of the body mass index (BMI) and documentation of the BMI in the health record

B.The Calculation of the body mass index (BMI) and recording of the BMI in the electronic patient information system

C.All women with BMI ≥30 should be advised to book for maternity team base care (Known as Shared Care at COCH).

D.All women with BMI ≥35 should be advised to deliver in obstetric led unit.

Management of Obese Women in Pregnancy

E.All women with a BMI ≥ 40 have an anaesthetic consultation with an OB Anaesthetist

F.Obstetric Anaesthetist management plan for labour and delivery should be discussed with all women with a BMI of ≥ 40.

G.Requirement that All women with BMI ≥30 have a documented antenatal consultation with an appropriately trained professional to discuss possible intrapartum complications.

H.Requirement to assess the availability of suitable equipment in all care settings for women with high BMI

I.Requirement for women with a booking BMI of ≥40 to have an individual documented assessment in the third trimester of pregnancy by an appropriate trained professional to determine manual handling requirements for childbirth and consider tissue viability.

J. The process for audit, multidisciplinary review of audit results and subsequent monitoring of action plans

REFERENCES

Appendix 1: Information for Pregnancies with Increased BMI

Appendix 2 Obesity Proforma

Appendix 3Manual handling assessment

Appendix 4Braden Score

Appendix 5 VTE Assessment

Appendix 6 Dietetic Outpatient Referral

Aim

The maternity service has approved documentation which describes the management of obesity in pregnancy that is implemented and monitored RATIONALE

The increasing prevalence of obesity in the UK has been widely publicised and the risks of maternal death among pregnant obese women has been highlighted by saving mothers lives (CEMACH 2007). The complications of obesity during pregnancy have far reaching implications for both mother and newborn. Maternity services must strive to manage the risks associated with obesity and pregnancy

Scope / Rationale

The increasing prevalence of obesity in the United Kingdom has been widely publicised and the risks of maternal death among pregnant obese women has been highlighted in Saving Mothers’ Lives (CEMACH 2007). Saving Mothers’ Lives (CMACE 2011) identified that when considering obesity alone, that is a BMI of 30 or more, 30% of mothers who died from direct causes were obese, as were 24% of women who died from indirect causes. The complications of obesity during pregnancy have far reaching implications for both mother and newborn. Obesity in pregnancy is associated with an increased risk of miscarriage, fetal congenital anomaly, thromboembolism, gestational diabetes, pre-eclampsia, dysfunctional labour, postpartum haemorrhage, wound infections, stillbirth and neonatal death. There is also a higher caesarean section rate in this group of women. Maternity services must develop and implement robust processes to manage the risks associated with obesity and consistently provide sensitive, comprehensive and appropriate multidisciplinary care.

Roles And Responsibilities

This policy applies to all midwifery, obstetric, medical and anaesthetic staff involved in providing maternity care to these women.

Process/Procedure

A.The Calculation of the body mass index (BMI) and documentation of the BMI in the health record

B.The Calculation of the body mass index (BMI) and recording of the BMI in the electronic patient information system

At antenatal booking all women must have their weight and height measured. Their BMI is then calculated and recorded on the patient’s Meditech maternity records. A copy is printed and filed in maternity health records.

The BMI is calculated as follows

BMI = weight (kg)/height (M) 2

Classification of BMI

BMIClassification

<18.5Underweight

18.5-24.9Normal Weight

25-29.9Overweight

30-34.9Obese

35-39.9Severely Obese

40 or moreMorbidly Obese

C.All women with BMI ≥30 should be advised to book for maternity team base care (Known as Shared Care at COCH).

D.All women with BMI ≥35 should be advised to deliver in obstetric led unit.

1. Midwifery Led CareBMI must be less than 30 to consider booking for midwife led care

2. Home Delivery BMI must be less than 35 for home delivery

3. Hospital DeliveryAdvise Hospital delivery if BMI ≥35

4. Shared CareAdvise Shared antenatal care if BMI ≥30

5. Anaesthetist ReviewOffer antenatal consultant anaesthetic review if BMI ≥40

Management of Obese Women in Pregnancy

Antenatal Care

The woman’s BMI should be accurately recorded on the Meditech antenatal booking history and a copy of this filed in the Personal Maternity Record and the Maternity Health records.
At booking the ‘Information for Pregnancies with increased BMI’ leaflet should be given (Appendix 1) and the Obesity proforma for pregnant women with a BMI ≥ 30 commenced (Appendix 2)
Shared antenatal care should be recommended for all women with BMI ≥30.
All women should be seen by a Consultant Obstetrician to discuss possible intrapartum complications.
Delivery within a Consultant unit should be recommended for all women with BMI ≥35.
The woman should be advised about the increased risks associated with her pregnancy and given the Obesity and Pregnancy information leaflet. See Appendix 1
Women with BMI ≥ 30 should have Obesity proforma completed and placed in their PMR see Appendix 2.

Antenatal Pregnancy Management should include

Documented plan of care in Maternity notes
Ensure folic acid 5mg has been commenced (stop at 14 weeks and then commence healthy start vitamins).
Consider Aspirin 75 mgs daily for duration of pregnancy in women with BMI ≥35, plus any other additional risk factor for pre- eclampsia. See Management of Antenatal Hypertension guideline.
Referral to see dietician should be offered to all women with raised BMI. If accepted then send written referral to either hospital dietician or to GP who can refer to community based dietetics service. Referral can also be requested via Meditech. Appendix 6
GTT should be arranged at 28/40 if BMI ≥30.
Serial growth scans should be arranged at 28 & 34 weeks if BMI ≥35
Review need for antenatal thromboprophylaxis with other associated risk factors

See Standard 3 Criterion 8

Usual guidelines for obstetric intervention should be used and planned delivery by induction or elective CS should be agreed by a Consultant.
Delivery by elective caesarean section should be considered and discussed with patients with BMI ≥50 .
All interventions should be planned if possible for a weekday during daytime hours. Arrangements should be for made to ensure that appropriate obstetric, anaesthetic, and midwifery staff are available
Any plan of care should be confirmed with consultant obstetrician, clearly documented, and discussed with and agreed by the woman.

Intrapartum Care

If the woman attends in spontaneous labour ensure all relevant staff and areas are informed.
The consultant obstetrician must be informed of admission if BMI is ≥40 to allow appropriate involvement with intrapartum care. The consultant obstetrician should be in attendance for any operative delivery of patients with a BMI ≥50
The anaesthetist covering labour ward must be informed of admission if BMI ≥40 to allow an assessment to be made of the likelihood of requiring operative delivery, any potential difficulties with venous access and neuraxial techniques, and potential difficulties with intubation. If appropriate management should be further discussed with relevant consultant anaesthetist
Obstetric Registrar Grade or above should be present on labour ward for delivery if BMI ≥40
All staff should maintain a low threshold for Consultant involvement in any aspect of care.
Planned delivery should be undertaken during the working week in normal working hours if possible.
All equipment should be in place to meet the woman’s special requirements.
On admission, bloods should be obtained for FBC, Group and Save.
Management of labour and fetal monitoring should be undertaken as indicated in current relevant labour ward guidelines
Thromboprophylaxis should be arranged using Meditech Maternity Thrombprophylaxsis guideline and scoring system see Appendix 5

Postnatal Care

Encourage early ambulation and continue management of pressure areas.
Confirm appropriate continuing thromboprophlaxis using Meditech scoring system
Contraceptive advice should reflect the high-risk of thromboembolic disease and an individual assessment of needs should be made in this respect. An IUS or the Mirena coil may be advisable.
Midwives should continue to offer ongoing support and reinforcing advice regarding healthy eating and exercise
Consider measures to help with weight reduction including referral to a Dietician.

E.All women with a BMI ≥ 40 have an anaesthetic consultation with an OB Anaesthetist

All women with BMI ≥40 are given an antenatal appointment with obstetric anaesthetist in anaesthetic antenatal review clinic.

F.Obstetric Anaesthetist management plan for labour and deliveryshould be discussed with all women with a BMI of ≥ 40.

Following obstetric anaesthetic consultation the anaesthetic management plan for labour and delivery is documented and filed in the patient’s medical record.

G.Requirement that All women with BMI ≥30 have a documented antenatal consultation with an appropriately trained professional to discuss possible intrapartum complications.

All women with BMI ≥30 should have an antenatal consultation with an appropriately trained professional i.e., midwife / OB doctor to discuss possible intrapartum complications.

H.Requirement to assess the availability of suitable equipment in all care settings for women with high BMI

Departmental Bariatric Risk equipment assessment is undertaken annually.
Any risk identified that cannot be controlled should be added to the departmental risk register and escalated to Divisional / Trust Risk register if appropriate.
The following equipment is available for appropriate management of obese women and in addition there is access to the Trusts bariatric manual handling equipment:

Location / Equipment Available
Antenatal clinic /

Walk on scales range up to 300kgs

2 large blood pressure cuffs

Labour Ward
Theatre /

Theatre operating table take weight up to 450 kgs
Ted stockings largest calf up to 56cm
Flowtron boots sizes 43cm to 71cm calf
3 Flowtron machines available
Operating support for retraction

Labour Ward /

Walk on scales range up to 300kgs

9 delivery beds range up to 227kgs

Ted stockings, largest size fits calf 56cms

3 large blood pressure cuffs
Voyager portable overhead lifter 200kg over delivery room baths

All Other Clinical Areas /

Pat slides and sliding sheets
Access to Mobile hoist stored on Ward 33/34

I.Requirement for women with a booking BMI of ≥40 to have an individual documented assessment in the third trimester of pregnancy by an appropriate trained professional to determine manual handling requirements for childbirth and consider tissue viability.

All women with BMI ≥40 must have a meditech manual handling score completed in third trimester by a midwife or doctor. Appendix 3
If Manual handling score falls into High category the tissue viability should be assessed using Braden Scoring system (meditech) Appendix 4

These guidelines cannot anticipate all possible circumstances and exist only to provide general guidance on clinical management to clinicians

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Obesity

J. The process for audit, multidisciplinary review of audit results and subsequent monitoring of action plans

Monitoring compliance with Maternity CNST Risk Management Standards Obesity Standard 3 Criterion 10

Minimum Requirements (Bold) / Process for monitoring / Responsible individual for Audit & action Plan / Frequency of audit / Responsible Committee for review of audit results & review of action plan
The Calculation and documentation of the body mass index (BMI) in the health records /

Annual audit of the process in the policy

/ Head of Midwifery / Annual / Women’s & Children’s Care Governance Board
The Calculation and documentation (BMI) in the electronic patient information system /

Annual audit of the process in the policy

/ Head of Midwifery / Annual / Women’s & Children’s Care Governance Board
Requirement that All women with a BMI of ≥40 have an antenatal consultation with OB Anaesthetist /

Annual audit of the process in the policy

/ Head of Midwifery / Annual / Women’s & Children’s Care Governance Board
Requirement that a documented OB anaesthetic management plan for labour and delivery should be discussed with all women with a BMI≥40 /

Annual audit of the process in the policy

/ Head of Midwifery / Annual / Women’s & Children’s Care Governance Board
Requirement that All women with BMI ≥30 should have a documented antenatal consultation with an appropriately trained professional to discuss possible intrapartum complications /

Annual audit of the process in the policy

/ Head of Midwifery / Annual / Women’s & Children’s Care Governance Board
Requirement for All women with a booking BMI of ≥40 to have an individual documented assessment in the third trimester of pregnancy by an appropriate trained professional to determine manual handling requirements for childbirth and consider tissue viability /

Annual audit of the process in the policy

/ Head of Midwifery / Annual / Women’s & Children’s Care Governance Board
Other policy requirements:
Requirement that all women with BMI ≥30 should be advised to book for maternity team based care.
Requirement that all women with BMI ≥35 should be advised to deliver in obstetric led unit.
Requirement to assess the availability of suitable equipment in all care settings for women with high BMI /

Clinical Incident review

/ Quality Improvement Facilitator / As required / Women’s & Children’s Care Governance Board

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Obesity

REFERENCES

Association of Anaesthetists of Great Britain and Ireland, and the Obstetric Anaesthetists’ Association. (2005). OAA/AAGBI Guidelines For Obstetric Anaesthetic Services (Revised edition). London: AAGBI/OAA. Available at: and

Confidential Enquiries into Maternal Deaths in the United Kingdom. (2011). Saving Mothers’ Lives: Reviewing Maternal Deaths To Make Motherhood Safer: 2006-2008. London: Wiley-Blackwell. Available at:

Centre for Maternal and Child Enquires, Royal College of Obstetricians and Gynaecologists (2010). Management Of Women With Obesity In Pregnancy. London: CMACE/RCOG. Available at:

Confidential Enquiry into Maternity and Child Health. (2004). Why Mothers Die 2000-2002. London: RCOG Press. Available at:

Confidential Enquiry into Maternity and Child Health. (2007). Saving Mothers’ Lives: Reviewing Maternal Deaths To Make Motherhood Safer - 2003-2005. London: CEMACH. Available at:

Centre for Maternal and Child Enquiries (2010). Maternal Obesity In The UK: Findings From A National Project. London: CMACE. Available at:

Department of Health. (2007). Maternity Matters: Choice, Access And Continuity Of Care In A Safe Service. London: COI. Available at:

National Institute for Health and Clinical Excellence (NICE). (2008). Antenatal Care: Routine Care For The Healthy Pregnant Woman. London: NICE. Available at:

Nursing and Midwifery Council (2008) The Code: Standards Of Conduct, Performance And Ethics For Nurses And Midwives. London: NMC. Available at:

Nursing and Midwifery Council. (2009). Record Keeping: Guidance For Nurses And Midwives. London: NMC. Available at:

Royal College of Obstetricians and Gynaecologists. (2006, 5 October). ‘The Growing Trends in Maternal Obesity’. RCOG Press Releases. Available at:

Royal College of Obstetricians and Gynaecologists, Royal College of Anaesthetists, Royal College of Midwives, Royal College of Paediatrics and Child Health. (2008). Standards For Maternity Care: Report Of A Working Party. London: RCOG Press. Available at:

NHSLA Maternity Standards 2012/13

Appendix 1: Information for Pregnancies with Increased BMI

Appendix 2 Obesity Proforma

Appendix 3Manual handling assessment

Appendix 4Braden Score

Appendix 5 VTE Assessment

Appendix 6 Dietetic Outpatient Referral

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