York Hospital Guidelines on Management of Obese Parturients

MATERNITY SERVICES GUIDELINE

OBESITY

Contents

Section Page

1. Guideline Flow chart3
2. Introduction & Definitions 3
3. Management4
4. Antenatal 5
5. Intrapartum5
6. Anaesthetic risks associated with obesity6
7. Postnatal7
8. Monitoring Compliance with the guideline8
9. Links with 8
10. References8

Appendix 1 Equipment available 9

Appendix 2 Guideline for use of equipment for overweight patients 10

Appendix 3 Monitoring Compliancy 11

Obesity Guideline Version 3 February 2012 Page 1 of 12

1. Guideline Flowchart

(refer to full guideline for further information)

• Should be given the patient information leaflet on obesity (raised BMI and lifestyle changes)
• Vitamin D 10mcg/day supplement ( prescribed by GP)
• Glucose Tolerance Test, arranged through Antenatal clinic at their 20 wk scan appointment.
• All women with a BMI ≥ 30 consider presentation USS on admission for labouring women and before IOL.
• They also need to be re- weighed again at 36 weeks.
• All women with a BMI≥30 should be recommended to have active management of the third stage of labour.

• Women with a BMI ≥ 35 must be booked consultant care and should have antenatal consultation with an obstetric consultant to discuss possible intrapartum complications, the discussion must be documented in the health record.
• These women are not suitable for midwifery led care and should be advised to deliver in hospital

• Women with BMI ≥40 at booking should be referred to the Lead Obstetric Anaesthetist irrespective of the planned mode of delivery. This is done by the consultant unit team at 20 wks scan appointment.
• The duty anaesthetist should also be aware of all women with a BMI ≥40 admitted to the maternity unit. The duty anaesthetist should be notified immediately of all women with a BMI ≥ 40 who are admitted in labour.
• All women in labour with a BMI ≥ 40 and above must have a grey cannula (16 gauge) sited together with a FBC and group and save sent to lab.
• In women with a BMI ≥ 40, a fetal scalp electrode should be applied to record the fetal heart rate if unable to obtain a good external CTG trace.
• BMI of 40 and above, regardless of their mode of delivery require Fragmin for 7 days. Patients at particularly high risk may need a 6- 8 week course of Fragmin.

2. Introduction & definition

Obesity is defined by the World Health Organisation (WHO) (1998) and the National Institutes of Health (1998) as a Body Mass Index (BMI) of ≥30.

Body Mass Index (BMI) is an index of weight-for-height. It is calculated by the weight in kilograms divided by the square of the height in metres (kg/m2)

The prevalence of obesity in pregnancy is on the rise and it is becoming increasingly more urgent to have guidelines and strategies in place to be able to give care to this group of women.

The role of this guideline is to outline the appropriate management strategies to minimise the clinical risk to this group of women.

In the last CEMACH (2007) report obesity alone was identified as a risk factor for maternal death, following the finding that 35% of all mothers who died were obese. It was recommended that women with a BMI ≥ 35 at first contact are unsuited for midwife led care and that they should deliver in a consultant unit with appropriate emergency facilities.

In order to make the pregnancy safer for obese women it should be acknowledged that they represent a “high risk pregnancy”

1. Management

Pregnancy risks associated with obesity:

Obesity is a recognised risk factor for a range of antenatal, intrapartum and postnatal complications with maternal BMI ≥ 30 being a recognised risk factor for:

• Hypertension and pre-eclampsia
• Gestational diabetes
• Difficulty with physical examinations
• Thromboembolic disease
• Fetal macrosomia
• Difficulty in monitoring fetal heart rate
• Prolonged labour
• Increased rate of LSCS
• Difficult operative procedures
• Risks associated with anaesthesia
• Wound infections
• Shoulder dystocia

• Maternal Death
• Failure to progress in labour

4. Antenatal:

1. All pregnant women must have an accurate measurement of height and weight taken at their booking visit (preferably, before 12 weeks) and BMI calculated. They also need to be re- weighed again at 36 weeks. This should be carried out by a healthcare professional using appropriate equipment. These measurements must be clearly documented in the women’s hand held notes and electronic patient information system. Self reported weights and height should not be used as substitutes.

1. Blood pressure readings must be recorded using an appropriately sized cuff.

1. Women with a BMI ≥ 30 and above should be given the patient information leaflet on ‘Raised BMI and Lifestyle Changes’ Women should be given the opportunity to discuss this information.

1. Women with BMI ≥30 at booking should have a Glucose Tolerance Test (GTT), arranged through Antenatal clinic at their 20 wk scan appointment. At the GTT appointment consideration will be given regarding midwifery led care or consultant led care. Women with a BMI ≥30 at booking are not currently booked for Consultant led care due to resources.

1. Women with a BMI ≥ 35 must be referred to a consultant obstetrician for Consultant led care. These women are not suitable for midwifery led care and should be advised to deliver in hospital with appropriate neonatal services.

1. Risks of pregnancy complications and morbidity should be discussed and recorded in the woman’s notes. Women with a BMI ≥ 35 must be booked consultant care and should have antenatal consultation with an obstetric consultant to discuss possible intrapartum complications, the discussion must be documented in the health record.

1. Women with BMI ≥40 at booking should be referred to the Lead Obstetric Anaesthetist irrespective of the planned mode of delivery, so that potential difficulties with venous access, regional or general anaesthesia can be identified. This is done by consultant unit team at 20 wks scan appointment or at subsequent appointment when a letter is sent to request the mother for an anaesthetic review. An individualised management plan should be written in the woman’s maternity notes and any specialised equipment identified. Dietary advice should be given and referral to dietician offered.

1. Venous thromboembolism Risk Assessment form to be completed at booking and on each admission to hospital.

5. Intrapartum:

1. All women with a BMI ≥ 30 consider presentation USS on admission for labouring women and before IOL.

1. All women in labour with a BMI ≥ 40 and above must have a grey cannula (16 gauge) sited together with a FBC and Group and Save sent to lab.
2. Administer oral Ranitidine 150 mg / 6 hourly, in labour. Consumption of food should be avoided, clear fluids only.

1. In women with a BMI ≥ 40, a fetal scalp electrode should be applied to record the fetal heart rate if unable to obtain a good external CTG trace.

1. All women with a BMI≥30 should be recommended to have active management of the third stage of labour.

1. All staff must follow the Trust Manual Handling policy, consider transferring and positioning.

1. A manual handling risk assessment on admission must be completed and reassess throughout labour and recorded 2 hourly in the maternity in patient notes.

1. Suitable equipment such as large BP cuffs are available in all care settings including the community. Large chairs, wheelchairs are available throughout the Trust for further information refer to Bariatric Guidelines in the Manual Handling Resource Pack or contact one of the Manual Handling Link Midwives. Also see (Appendix 1) Maximum Load Weight of Equipment and (Appendix 2) Guideline for use of equipment for overweight patients. This equipment will be assessed annually by the Manual Handling Link Midwives.

6. Anaesthetic risks associated with obesity:

Practical: Transferring and Positioning

Practical procedures such as IV access, regional anaesthesia, intubation, mask ventilation

Special equipment needed such as stronger beds and tables

Monitoring

Associated conditions:Diabetes

Sleep apnoea

Hypertension

Gastro-oesophageal Reflux

The duty anaesthetist should also be aware of all women with a BMI ≥40 admitted to the maternity unit, as they may have additional risks and potential difficulties.

The duty anaesthetist should be notified immediately of all women with a BMI ≥ 40 who are admitted in labour. A consultant anaesthetist (Specialty Trainee year 6 and above) should be informed and available for the care of women with a BMI ≥40 during labour and delivery, including attending any operative vaginal or abdominal delivery advising what analgesia or anaesthetic should be used.

If a delivery plan is available the duty anaesthetist should follow it. If it is not they should assess the woman paying particular attention to:

Airway assessment

Any history or suspicion of obstructive sleep apnoea

Any coexisting disease

A multidisciplinary delivery plan should be formed considering the obstetric risk in light of high BMI and any additional anaesthetic concerns.

Extra care should be taken to avoid lying a women flat as aorta compression is exacerbated. This must never be under estimated.

The high risks of a general anaesthetic in this group coupled with the likelihood of difficulty with regional anaesthesia mean that siting an epidural early in labour, when there is no urgency and calling of a 2nd anaesthetist if necessary, seems the prudent and safest choice. This should be explained to the woman, who should have had this discussed antenatally. Once an epidural is sited the anaesthetist must ensure it is working well and continues to work well in case it needs to be topped for a theatre procedure later.

If theatre is needed a general anaesthetic should be avoided if at all possible. A senior anaesthetist should be involved. Extra monitoring may be required (e.g. arterial line as non-invasive cuffs tend to misread) and HDU care may well be needed post operatively. Good analgesia is essential but opiates will exacerbate sleep apnoea and reduce mobility postoperatively. Other points for consideration

Sitting up for pre-oxygenation and intubation

Ensuring adequate suxamethonium is given

Inducing and siting regional anaesthesia in theatre so that she doesn’t have to be moved on the table

Sitting her up before extubation

Getting extra people into theatre to help with positioning

7. Postnatal:

1. Early mobilisation

1. Particular risks are concealed PPH, Obstructive Sleep Apnoea difficulties measuring BP, DVT, slow mobilisation and wound infection

1. Consider use of HDU facilities post delivery due to risks of respiratory and cardiovascular complications.

1. Refer to physiotherapists, as indicated.

1. Postnatal VTE risk assessment completed and appropriate Fragmin should be prescribed doses appropriate for maternal weight. Refer to thrombo prophylaxis guideline.

1. BMI of 40 and above, regardless of their mode of delivery require Fragmin for 7 days. Women at particularly high risk may need a 6- 8 week course of Fragmin.
2. Dietary advice should be given and referral to dietician offered.

1. It is also recommend for future pregnancies that women receive pre-pregnancy counselling and folic acid supplementation.

8. Monitoring Compliance: See Appendix 1

This will be monitored as part of the Annual Audit Programme.

The lead person will be responsible for completion of the monitoring process by means of an audit, development of an action plan, any subsequent actions and their dissemination.

• Obs & Gynae Clinical Governance Forum
• Labour Ward Forum & Obstetric Risk Group

• Obs & Gynae Clinical Governance Forum

9. Links with:

Bariatric Guidelines in the Manual Handling Resource Pack

Pregnancy and Obesity Patient Information Leaflet

Home Birth guideline

Thrombo-prophylaxis guideline

Antenatal Day Services guideline

10. References:

M Dresner, J Broklesby, J Bamber: Audit of the influence of BMI on the performance of epidural analgesia in labour and the subsequent mode of delivery. BJOG. Vol113. Issue10.

ROCOG (2010) Joint Guideline: Management of Women with Obesity in Pregnancy London

Centre for Maternal and Child Enquiries (CMACE). Maternal obesity in the UK: Findings from a national project. London: CMACE, 2010.

U Krishnamoorthy, CMH Schram, Sr Hill: Maternal obesity in pregnancy: is it time for meaningful research to inform preventive and management strategies? BJOG. Vol 113 Issue 10.

Lewis, G (Ed) 2007: The Confidential Enquiry into Maternal and Child Health (CEMACH). ‘Saving Mothers’ Lives: Reviewing Maternal Deaths to Make Motherhood Safer-2003-2005’. The Seventh Report on Confidential Enquiries into Maternal Deaths in the United Kingdom. London: CEMACH.

National Institute for Health and Clinical Excellence (NICE) 2008: Clinical guideline 62: Antenatal care: Routine care for the healthy pregnant woman. London

Richens Y,(2008) Tackling maternal obesity: Suggestions for midwives. British Journal of Midwifery: vol16: 1p 14-18.

CKH Yu, TG Teoh, S Robinson: Obesity in pregnancy. BJOG Vol113, issue 10.

Appendix 1 Equipment available

Maximum Load Weight of Equipment

See Manual Handling Bariatric Flowchart for Trust equipment availability

Further information available from the Manual Handling Resource Folder

Obesity Guideline Version 3 February 2012 Page 1 of 12

Appendix 2

GUIDELINES FOR USE OF EQUIPMENT FOR OVERWEIGHT PATIENTS

 Remember weight now, not booking weight.

 36/40 weight may need checking on admission if close to the upper weight limit.

• Scales on G3 weigh up to 190kg, may use 2 scales if required.
• Scales on G1 weigh up to 200kg
• Liko Gantry scales weigh up to 317kg – phone works (ext 5566) will need requisition.

 Refer to guidelines for very heavy patients/bariatric patients.

 Refer to pool guidelines re: exclusion criteria.

Appendix 3

Monitoring Compliance

In order to monitor compliance with this guideline, this guideline will be monitored as follows:

Obesity Guideline Version 3 February 2012 Page 1 of 12