Managing Labor and Delivery
For your obese patient
Labor management decisions
Tension between Hope for successful vaginal delivery and fear of
emergency cesarean deliveryAvoidance of desultory labor and avoidance of
impatience
Goals
Healthy mom Healthy baby Meaningful birth experience Maternal dignity Environment of safety
Labor problems
Greater number of inductions Difficult to monitor Difficult placement and function of epidurals Dysfunctional labor patterns ?Effect on duration of labor Failed inductions, more cesareans
Management of medical co-morbidities
DiabetesMonitoring Insulin
Hypertension/preeclampsiaMagnesium Antihypertensives
Cardiac disease
Chance of primary cesarean
Observational cohort study 2007 4341 consecutive term, singleton nulliparas OR 3.8 for BMI >35 compared with BMI <25 after
adjustment for variables No single explanation
Cesarean section for abnormal labor
Increased number of large-for-gestational-age infants
Suboptimal uterine contractions Increased fat disposition in the soft tissues of
the pelvis
Complications of delivery
More operative vaginal deliveries Postpartum hemorrhage Increased rate of primary cesarean birth Increased OR time Increased wound infections Increased rate of endometritis Risk of thromboembolic events
Maternal morbidity - Complications of delivery
Weiss 2004 (compare normal, obese and morbidly obese) Induction of labor OR 1.6 Failed induction
7.9%, 10.3%, 14.6% Primary cesarean delivery
20.7%, 33.8%, 47.4% Shoulder dystocia
1%, 1.8%, 1.9% Increased operative vaginal delivery Increased emergency cesarean delivery
VBAC Hibbard 2006 (SMFMU) 14,142 TOL 14,304 ERCS 4 BMI categories (morbid obesity >40 BMI) No data about counseling, indication for prior
delivery, intrapartum care. Inadequate data to assess death or neurologic damage
Success of VBAC Normal weight 85% Morbid obesity 60%
Rupture/dehiscence Normal weight 0.9% Morbid obesity 2.1 %
VBAC Compare TOL vs ERCS in morbidly obese
Outcome TOL ERCS OR
Rupture/
dehiscence
2.1% 0.4% 5.6
Maternal morbidity
7.2% 3.8% 1.9
Neonatal
injury
1.1% 0.2% 5.1
VBAC Hibbard, 2006 Compare successful and failed VBAC
Outcome Failed Success OR
Maternal morbidity
14.2% 2.6% 6.1
Rupture/
Dehiscence
4.6% 0.5% 9.7
Anesthesia consultation Difficult IV access Airway obstruction Rapid desaturation with apnea (↓FRC) Difficulty with ventilation Challenging regional anesthesia Slower pace of initiating anesthesia for cesarean
section Consider prophylactic epidural
Delivery considerations
Type and screen, CBC Consider thromboprophylaxis Place a block of wood to support under
the toilet of the patient’s bathroom Equipment: appropriate sized
wheelchair, commode, bed
What else helps? Ultrasound Internal fetal monitoring Maternal monitoring
Careful BP cuff sizeSerial BP/pulse oximetry?Arterial line
Careful Is and Os
Mechanics Assess ability to flex, external rotation Labor and push on side Assistance for thigh retraction Suprapubic pressure under pannus Step stools at side of bed Take care to avoid maternal injury
Prevent wound infection
Diabetes – treat hyperglycemia Rupture of membranes – avoid early
AROM Multiple vaginal exams- limit exams Treat chorioamnionitis
Postpartum care Early ambulation after delivery Sequential compression devices until
ambulatory without assistance Or continue heparin until ambulatory
without assistance Assure that patient completely changes
position in bed q 2 hours
Breast is best
Decreases rate of obesity in offspring Helps mom lose weight
Guiding questions
What is the patient’s BMI? Are there co-morbidities? Is there a history of surgical or anesthesia
complications? Does my hospital have the necessary equipment,
personnel, protocols?
Elements of care plan
Frank discussion regarding risks-consider written document/consent
Anesthesia consult EFW before admission (?how)
?early delivery/avoid macrosomia Criteria for primary cesarean
Elements of care plan
Safety huddle on admission (? repeat)Assure all team members are availableEquipment check list Identify roles for
Emergency cesareanShoulder dystocia
Elements of care plan
Lab: Type and screen, CBC Secure IV access Thromboprophylaxis Maternal and fetal monitor
Continuous EFM, tocoBP cuffsGlucometer
Other considerations ? Postpone other elective patient care Set expectations for labor progress
When to consider cesareanWhen to consider (or not) operative vaginal delivery
Induction issuesCervical ripeness criteriaDuration of ROMMinimize length of hospitalization