WOMEN AND NEWBORN HEALTH SERVICE King Edward Memorial Hospital

1
WOMEN AND NEWBORN HEALTH SERVICE
King Edward Memorial Hospital
CLINICAL GUIDELINES
SECTION B : OBSTETRICS AND MIDWIFERY CARE
2 COMPLICATIONS OF PREGNANCY
Date Issued:
Date Revised:
Review Date:
Authorised by:
Review Team:
July 2009
September 2013
September 2016
OGCCU
OGCCU
2.21 Management of pregnancy and childbirth in women with a BMI > 35
Section B
Clinical Guidelines
King Edward Memorial Hospital
Perth Western Australia
Key words: body mass index, obesity, pregnancy
2.21 MANAGEMENT OF PREGNANCY AND CHILDBIRTH IN
WOMEN WITH A BODY MASS INDEX ABOVE 40
Background
Key points
Antenatal
•
Classification of Body Mass Index (BMI)
• Management
Intrapartum Management
Postpartum Management
References
KEY POINTS
1.
All antenatal women attending KEMH should have their BMI (according to their pre-pregnancy
weight or the earliest weight in pregnancy) done at the first visit.
Women with a BMI ≥ 35 are not suitable to attend a low risk midwives clinic and should be
referred to an obstetric medical team for pregnancy management
All antenatal women with an increased BMI should be referred to the Dietician.
Women should be monitored for anaemia, and iron supplementation commenced as per
KEMH Clinical Guidelines- B.2.23 Anaemia in pregnancy
Women with a BMI ≥ 50 or (< 50 but with significant co-morbidities) shall be referred to the
high-risk anaesthetic clinic for review between 28 – 34 gestation.
Women who have had bariatric surgery require closer monitoring for nutritional deficiencies,
and monitoring of fetal growth. Studies have indicated a trend towards increased risk for the
small for a gestational age fetus, intra-uterine growth restriction, and a decrease in birth
weight. Referral to the Dietician should be considered.
Patient handling shall comply with the WNHS Policy W016 Heavy Patient Management
2.
3.
4.
5.
6.
7.
AIM
To provide optimal care for obese pregnant women to decrease risk and improve outcomes for
pregnancy, birth and postnatally.
BACKGROUND
There is substantial evidence to indicate that obesity in pregnancy contributes to increased morbidity
and mortality for both the mother and baby. The Confidential Enquiry into Maternal and Child Health
(CEMACH) Perinatal Mortality 2005 report found that approximately 30% of mothers who had a
2009
All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual
Page 1 of 8
stillbirth or a neonatal death were obese. The CEMACH (2007) report indicated that more than half of
1
the women who died from direct / indirect causes were obese.
MATERNAL RISKS ASSOCIATED WITH OBESITY
These include:
•
early miscarriage
•
stillbirth – obesity carries a 2-3 fold increased risk for intrauterine fetal death even after co5
existing medical complications have been controlled (e.g. hypertension and diabetes)
•
hypertension and pre-eclampsia
•
diabetes – is about three times more common in obese women
2, 3
2, 4
2, 5-8
A raised BMI increases risk for pre-eclampsia by 50%
9
2, 4
•
labour – increased risk for induced labour , failed induction of labour , failure to progress ,
8
5
5
instrumental delivery , shoulder dystocia , birth trauma
•
caesarean / instrumental delivery – due to failed or obstructed labour , and likelihood of
5
successful vaginal birth after caesarean is very low
•
nutritional and micronutrient deficiency e.g. folate deficiency
5, 9
5
8
5
4
•
anaesthetic complications
•
wound infections
•
preterm labour and delivery
•
less likelihood of initiation and maintenance of breastfeeding . Delayed lactogenesis is
7
common.
•
thromboembolism
•
postpartum haemorrhage
9
9
5, 7
9
8
5
FETAL AND NEONATAL RISKS ASSOCIATED WITH OBESITY
These include:
8
•
congenital anomalies e.g. neural tube defects, congenital heart defects
•
macrosomia
•
early neonatal death
•
increased risk of development of obesity and metabolic disorders in childhood
4, 8
and associated birth injuries
4
4, 9
9
ANTENATAL
CLASSIFICATION OF THE BODY MASS INDEX
2
BMI is weight in kilograms divided by height in metres squared (i.e. kg/m )
2
Classification
BMI (kg/m )
Normal
18.5 – 24.9
Overweight
25 – 29.9
Obese I
30 – 34.9
Obese II
35 – 39.9
Obese III
Greater than or equal to 40.0
Table 1. World Health Organisation BMI Classification
Date Issued: July 2009
Date Revised: September 2013
Review Date: September 2016
Written by:/Authorised by: OGCCU
Review Team: OGCCU
2009
10
2.12 Management of pregnancy and childbirth with a BMI >35
Section B
Clinical Guidelines
King Edward Memorial Hospital
Perth Western Australia
All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual
Page 2 of 8
ANTENATAL MANAGEMENT- IN ADDITION TO STANDARD CARE
Ref to Clinical Guideline B.1.1.3 Ante partum Clinic-- Initial Visit and B.1.1.4 Ante partum ClinicSubsequent Visits
Topic
Management
Additional Information
Triaging of antenatal
visits
Routine scheduled antenatal visits may
need to be adjusted to be more frequent
according to the level of obesity and risk
factors. Refer to BLOOM, RANZCOG
brochure “Weight management during
Pregnancy” sent to patient with
appointment.
Calculation of the
BMI
At the booking visit the BMI is calculated
according to the pre-pregnancy weight, or
the earliest weight in pregnancy.
Monitoring of weight
Document the woman’s weight at each
visit.
The Institute of Medicine
recommendation for women
with a BMI ≥30 is 5–9 kg weight
2, 8
gain in pregnancy.
Ensure FBP and iron studies are obtained
and followed up appropriately at 28 and
36 weeks gestation.
Women with a BMI ≥ 30 are at
increased risk of vitamin D
9, 11
deficiency.
Obesity increases risk for fatty
7
liver disease.
Dietary habits may result in
nutritional deficiencies including
11
iron, B12, vitamin C and folate.
Anaemia monitoring
and prevention and
optional tests
Diabetes Screening
Consider screening for:
•
•
•
•
Vitamin D deficiency
Liver function tests
B12
Folate
Women with obesity should have early
screening for diabetes, preferably at the
7
time of first antenatal attendance.
If early screening is normal, repeat the
screening at 24 - 28 weeks gestation.
Anaesthetic referral
Arrange an anaesthetic review in the high
risk anaesthetic clinic between 28 - 34
weeks gestation for women with a BMI
≥50
≤50 if significant co-morbidities exist
(OSA, IDDM, Previous complications with
anaesthesia, back problems, previous
difficult epidural placement etc.)
Date Issued: July 2009
Date Revised: September 2013
Review Date: September 2016
Written by:/Authorised by: OGCCU
Review Team: OGCCU
2009
Affix Bloom sticker in MR 004
and RANZCOG sticker in
MR 222
Obesity promotes exaggeration
of insulin resistance that is
observed in pregnancy,
therefore these women may
have pre-existing diabetes
5
mellitus.
Diabetes is three times more
4
common in obese women. See
Clinical Guideline, Section B
3.1.1 Screening for Diabetes in
Pregnancy.
Potential difficulties with venous
access, regional or general
anaesthesia may be identified.
Women with a BMI ≥ 40 are
classified as high risk for
anaesthesia-related maternal
9
mortality.
Obese women have up to a
33% higher risk for difficult
12
intubation , are at increased
2.12 Management of pregnancy and childbirth with a BMI >35
Section B
Clinical Guidelines
King Edward Memorial Hospital
Perth Western Australia
All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual
Page 3 of 8
Topic
Management
Additional Information
risk of aspiration, postoperative
atelectasis, and difficulties with
9
epidural placements.
Ultrasounds
Where possible fetal morphological
assessment should be performed at 20 3
22 weeks rather than 18 – 20 weeks
gestation. Note the presence of obesity
on the ultrasound form.
Perform an ultrasound for fetal weight,
amniotic fluid volume, and umbilical
Doppler studies in the third trimester (2834 weeks) to assess fetal growth. A
minimum of two growth scans are
recommended with additional scans if
indicated.
Obesity leads to reduced
ascertainment of anatomy at
4
screening.
Fundal height measurements to
assess growth is impeded
physically by maternal body
5
habitus.
Nutritional
Management
Refer women to the Dietician.
Thromboembolic
Prophylaxis
Consider prophylactic low molecular
weight heparin for women with two or
9
more additional risk factors for VTE.
Maternal obesity is associated
with significant risk of
thromboembolism during the
9
antenatal and postnatal period.
History of Bariatric
surgery
Medical history should include nutritional
habits.
Consider performing investigations for
mineral and vitamin deficiencies in early
2, 12
pregnancy.
A multivitamin from the beginning of
pregnancy may be beneficial for women
2
who have had bariatric surgery.
Circumstances that may require closer
monitoring include vomiting or a history of
2, 13
poor nutrition.
Nutritional deficiencies such as
low levels of vitamin B12, folic
acid, ferritin, and calcium have
been found in some studies,
however systematic studies
13
have failed to confirm this.
Monitor fetal growth. Perform ultrasound
assessment for growth and fetal wellbeing
as required.
Bariatric surgery may lead to
increased risk for a small for
gestational age (SGA) fetus,
preterm delivery, and perinatal
14
mortality. Neonates show a
trend toward lower birth weight
rates, less macrosomia, and an
increase in intrauterine growth
2, 4, 14
restriction (IUGR).
Women who have had bariatric
surgery are at higher risk for
13
gestational diabetes.
Previous caesarean
section
Date Issued: July 2009
Date Revised: September 2013
Review Date: September 2016
Written by:/Authorised by: OGCCU
Review Team: OGCCU
2009
Discuss risks and outcomes for vaginal
birth after caesarean (VBAC).
For obese women who have
previously delivered by
caesarean section, the
likelihood of successful VBAC is
very low. Obese III women also
carry a higher risk for uterine
5
scar dehiscence.
2.12 Management of pregnancy and childbirth with a BMI >35
Section B
Clinical Guidelines
King Edward Memorial Hospital
Perth Western Australia
All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual
Page 4 of 8
Topic
Elective caesarean
section.
Management
Additional Information
Book a preadmission clinic appointment
Document the BMI on the theatre booking
form.
Where possible urinary catheterisation
should be performed prior to insertion of
the epidural block.
Alerts the theatre and
anaesthetic staff to allow
preparation of equipment and
personnel.
Encourage 30 minutes of low-intensity
15
exercise e.g. walking.
Excessive weight gain is
correlated to fetal macrosomia,
operative vaginal and caesarean
delivery and adverse neonatal
5
outcomes.
Limiting weight gain rather than
weight loss is the goal in
5
pregnancy.
Education
•
Exercise
Women who are not physically active
should be encouraged to increase activity
by gradually walking up to 30 minutes a
day – this can be achieved by dividing the
total time into shorter, multiple periods of
15
exercises if preferred.
•
Weight gain in
nd
rd
the 2 and 3
trimester.
Overweight (BMI 25-29.9) – total weight
16
gain recommended is 7 to 11 kg.
Obese (includes all classes) total weight
16
gain recommended is 5 to 9 kg.
•
Birth Planning
Occupational Health
and Safety Issues
and Manual Handling
Assessment
Observational studies have
shown that women whose
weight gain follows the
guidelines of the Institute of
Medicine, have better outcomes
17
in pregnancy.
Home birth or water birth is not
recommended.
Note and document any physical
limitations.
Arrange specialised equipment as
required.
INTRAPARTUM MANAGEMENT- IN ADDITION TO STANDARD CARE
Refer to Clinical Guideline B.5.8.1 Care of a woman during the first stage of labour
B. 5.9.1 Management of the second stage of labour
PREPARATION
Ensure manual handling equipment is available and used e.g. hoists, hover mats
Date Issued: July 2009
Date Revised: September 2013
Review Date: September 2016
Written by:/Authorised by: OGCCU
Review Team: OGCCU
2009
2.12 Management of pregnancy and childbirth with a BMI >35
Section B
Clinical Guidelines
King Edward Memorial Hospital
Perth Western Australia
All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual
Page 5 of 8
MATERNAL MANAGEMENT
•
Inform the Midwifery Co-ordinator and Obstetric Team when a woman with a BMI ≥ 40 arrives
in labour.
•
Ensure venous access with a large gauge cannula when labour is established.
•
Collect a blood group and hold when the intravenous access is performed. Women with an
increased BMI are at higher risk for postpartum haemorrhage and intrapartum complications.
•
Blood pressure measurement should be taken with an appropriately sized cuff.
•
Consider the use of a scan to confirm presentation, particularly if there is uncertainty regarding
presentation.
•
Measure and fit graduated compression stockings.
•
Consider commencing treatments to decrease risk for gastric aspiration if there are indications
a caesarean section may be required. Extremely obese women have a greater likelihood of
5
emergency caesarean section. See Clinical Guideline, Section B 7.3 Prevention of gastric
aspiration in pregnant women.
•
Early epidural placement should be considered.
•
Where possible insert urinary catheters (if required) prior to an epidural insertion.
•
Active management of the third stage is recommended to decrease risk of postpartum
haemorrhage
9
FETAL MONITORING
A fetal scalp electrode may be required to monitor the fetal heart rate when continuous external
monitoring is unable to be obtained.
An intrauterine pressure transducer (IUPT) may be required if external assessment of the uterine
activity is unable to be done effectively with a toco transducer. Ref. Clinical Guideline B.5.8.4
Intrauterine Pressure Catheter Insertion
ANAESTHETIC CONSIDERATIONS
•
Inform the Anaesthetist/Anaesthetic Registrar and theatre Co-ordinator on admission of any
9
women with a BMI ≥ 50.
•
If regional analgesia is the preferred choice of pain relief, the epidural catheter should be sited
early.
POSTPARTUM MANAGEMENT- IN ADDITION TO STANDARD CARE
Refer to Clinical Guideline B.6.1 Immediate Care of Mother in LBS following birth and B.6.2.2
Subsequent Care
Consider transfer of the woman back to a peripheral hospital (if no other complications) after birth.
STRATEGIES TO DECREASE RISK FACTORS
•
Encourage early mobilisation.
•
Avoid dehydration.
•
Management to decrease risk of venous thromboembolism (VT6E):

All women with a BMI ≥40 should be given postnatal thromboprophylaxis regardless of
9
the mode of delivery.

Post caesarean – women should wear graduated compression stockings and venous
8, 18
This
thromboembolism (VTE) prophylaxis (pharmacological) should be given.
should be continued for 5-7 days or until the patient is fully mobile, however, it should
18
be extended for 6 weeks postnatally in high risk women.
5, 8, 9
Date Issued: July 2009
Date Revised: September 2013
Review Date: September 2016
Written by:/Authorised by: OGCCU
Review Team: OGCCU
2009
8
2.12 Management of pregnancy and childbirth with a BMI >35
Section B
Clinical Guidelines
King Edward Memorial Hospital
Perth Western Australia
All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual
Page 6 of 8

•
Post vaginal birth – if other risk factors are present for VTE, then prophylaxis
(pharmacological) should be given to all women with obesity, and the women
encouraged to wear graduated compression stockings.
Educate the woman about strategies to decrease risk for VTE.
BREASTFEEDING
Women may require additional assistance with breastfeeding e.g. positioning
CONTRACEPTION
Discuss contraception options.
Inform the women that oral contraceptives are less efficacious in women weighing over 90kgs.
However, this has not been the case with intrauterine devices or injectable or implantable
7
contraceptives.
PRECONCEPTION COUNSELLING
Provide advice regarding:
•
The risks for falling pregnant in the future
•
The associated risks of further caesarean sections for women with two or more caesarean
sections, including information of operative procedures in obese III women as well as the risk
of placenta praevia/accreta.
•
The commencement of folic acid 5mg/day to decrease the risk of neural tube defects
•
Bariatric surgery – if the woman is considering this option it is recommended to delay
8
pregnancy for 18 months during the rapid weight loss period.
•
Postpartum depression – this has been reported to correlate positively with BMI and can be as
5
high as 40% in class III obesity.
8
8
GENERAL PRACTITIONER FOLLOW-UP
Women who have gestational diabetes should have an oral glucose tolerance test at 6 weeks
postpartum. Ref. Clinical Guideline B.6.2.3.1 Transfer of a postnatal woman to Home/ VMS, GP care
REFERENCES
1.
2.
3.
4.
5.
6.
7.
8.
9.
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Magdaleno R, Pereira BG, Chaim EA, Turato ER. Pregnancy after bariatric surgery: a current
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Society of Obstetricians and Gynaecologist of Canada. Clinical Practice Guideline, No. 239.
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McGuire W, Dyson L, Renfrew M. Maternal obesity: consequences for children, challenges for
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Gunatilake RP, Perlow JH. Obesity and pregnancy: clinical management of the obese gravida.
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Nodine PM, Hastings-Tolsma M. Maternal Obesity: Improving Pregnancy Outcomes.
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Thornburg LL. Antepartum Obstetrical Complications Associated with Obesity. Seminars in
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Tsoi E, Shaikh H, Robinson S, Teoh TG. Obesity in pregnancy: a major healthcare issue.
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J Modder and KJ Fitzsimons for the Centre for Maternal and Child Enquiries and the Royal
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Date Issued: July 2009
Date Revised: September 2013
Review Date: September 2016
Written by:/Authorised by: OGCCU
Review Team: OGCCU
2009
2.12 Management of pregnancy and childbirth with a BMI >35
Section B
Clinical Guidelines
King Edward Memorial Hospital
Perth Western Australia
All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual
Page 7 of 8
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Date Issued: July 2009
Date Revised: September 2013
Review Date: September 2016
Written by:/Authorised by: OGCCU
Review Team: OGCCU
2009
2.12 Management of pregnancy and childbirth with a BMI >35
Section B
Clinical Guidelines
King Edward Memorial Hospital
Perth Western Australia
All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual
Page 8 of 8