health: n · women with bmi ≥ 35 have an increased risk of pre-eclampsia and should be risk...

1

Health: N

Women & Children’s Health Maternity Guideline

Obesity in pregnancy

Patient information on app/ website: Yes

The Management of the morbidly obese woman

Version Reason for review Ratified

Authors; Judith Hyde (Consultant ) and members of the Southwest Obstetric Network

1 New guideline September 06 SWON Network

Cathy Winter Practice Development Midwife Sharyn McKenna Clinical Risk Manager

2 Adapted by NBT. Action Plan added

Ratified by NBT AN Screening group, intrapartum and postnatal clinical teams Nov 2007

Sharyn McKenna Clinical Risk Manager; Isaac Babarinsa (Senior Registrar); Tim Draycott

3 Updated re Thromboprophylaxis Guidance and CEMACH

Ratified by intrapartum clinical team. 3-10-08 Release Date: 23

rd October 2008

Review Date: July 2011

Elinor Medd (ST5), Sonia Barnfield (Senior registrar)

4 CNST revision: Dec 2009 Release date: Jan 2010

Dec 2009 Review date: Oct 2012

Sarah Platt (ST4), Judith Hyde (Consultant), Sonia Barnfiedl (Consultant)

5 January 2012 New care pathways and new national guidance

Ante Natal Clinical Team April 2012 Released 26

th April 2012

Sarah Newell (ST3), Sonia Barnfield (Consultant)

6 Added “Surgical and anaesthetic care Pathway for women with BMI > 50”

Intrapartum clinical team. 24/06/13

Review January 2015

7 Updated with SGA Guideline March 2017

7.1 Minor changes to BMI care pathways in line with place of birth – CBC and MBC & home

Date changes made 13/12/17

7.2 Increase in aspirin to 150mg 16 May 2019- launched June 2019 review Dec 2020

Corrected typo on page 3 where it read “All women with BMI ≥ 40 should be prescribed oral Aspirin tablets 155mg daily”

7.4 Care Of Women in the community with BMI ≥ 30 and <40 at booking in pregnancy

23 July 2019

7.5 New template 1 October 2019

7.6 Aspirin dose and advise when to stop taking added November 2019

Review Dec 2020

7.7 Minor Changes to Align with Hypertension Guidelines around Aspirin.

5/2/2020 Ratified outside Meeting

2

Background and Definitions Maternal Obesity has become one of the most commonly occurring risk factors in obstetric practice. All women should have their weight and BMI calculated at booking and at 34 weeks. Obesity is usually defined as a Body Mass Index (BMI) of 30kg/m² or greater at first antenatal consultation or at 34 weeks gestation. The prevalence of obesity in the general population in England has increased markedly since the early 1990s, and within the pregnancy population there has been an increase from 9-10% in the early 1990s to 16-19% in the 2000s. There are 3 different classes of obesity: Class 1: BMI 30.0 to 34.9 Class 2: BMI 35.0 to 39.9 Class 3 (or morbid obesity): BMI 40 and over These different classes recognise the continuous relationship between BMI and morbidity and mortality.

3

Best Practice Points (Refers to BMI at booking)

Women should have the opportunity to optimise their weight before pregnancy in the Primary Care setting

All women with a BMI ≥ 30 should have folic acid 5mg and Vitamin D 10 mcg

All women should be provided with accurate and accessible information about the risks associated with obesity in pregnancy and how they may be minimised. They should also have the opportunity to discuss this information.

All women with BMI ≥ 30 should be screened for gestational diabetes at 24-28 weeks gestation

All women with BMI ≥ 40 must be given an Anaesthetic information leaflet.

Women with BMI ≥ 35 with additional risk factors should be recommended to take aspirin 150mg OD from 12 to 36 weeks (see Section 2 of this guideline and/or page 14 of the handheld notes)

Women with BMI ≥ 30 should have an informed discussion antenatally about possible

intrapartum complications associated with a high BMI (slow labour progression, shoulder dystocia, emergency caesarean section and postpartum haemorrhage) and management strategies considered.

Active management of third stage should be recommended for all women regardless of BMI.

Women with a BMI <35 may give birth at Cossham Birth Centre/ Home.

Women with a BMI ≥35-39.9 may give birth in Mendip Birth Centre.

Women with a BMI ≥ 40 should give birth in a consultant-led obstetric unit with appropriate neonatal services.

All women with BMI ≥ 40 should be prescribed oral Aspirin tablets 150mg daily (Women, who need to take Aspirin 150mgs in pregnancy, should be advised to start taking

from 12 weeks gestation, take it in the evening and to stop at 36 weeks gestation)

Obesity is associated with low breastfeeding initiation and maintenance rates. Specialist advice and support should be offered.

Long acting Reversible progesterone-based contraceptives (LARC) should be advised

4

Introduction

Obesity in pregnancy is associated with an increased risk of a number of serious different outcomes:

Miscarriage

Fetal congenital anomaly

Thromboembolism

Gestational Diabetes

Pre-eclampsia

Dysfunctional labour

Postpartum Haemorrhage

Wound infections

Stillbirth

Neonatal death See appendix re absolute risks.

There is also a higher caesarean section rate and lower breastfeeding rate. The 2003-2005 Confidential Enquiry into Maternal and Child Health reported that 28% of mothers who died were obese, and as the prevalence of obesity in the general maternity population at that time was 16-19%, this suggests that obesity may also be a risk factor for maternal death.

1. Pre-pregnancy Care

Women should have the opportunity to optimise their weight before pregnancy in the Primary Care setting

o Weight and lifestyle advice during family planning consultations o Regular monitoring of weight, BMI and waist circumference. o Information about the risks of obesity during pregnancy and childbirth should be

provided.

Nutritional Supplements for women with BMI ≥ 30 o Folic acid 5mg supplementation daily, starting at least one month before

conception and continuing during first trimester of pregnancy o Vitamin D 10 micrograms daily during pregnancy and while breastfeeding found in

Pregnacare or healthy start vitamins.

2. Antenatal Care All women should have their weight and BMI calculated at booking and 34 weeks and recorded in handheld record and Euroking.

Women with BMI ≥ 30 and <40 should be cared for in the community with close adherence to the designated antenatal care pathway (see appendix) Note that if BMI ≥ 40 at 34 weeks gestation, consultant referral is required and SGA guideline should be followed.

Women with BMI ≥ 40 require referral to Consultant-led care

5

Women with BMI ≥ 50 require referral to Endocrine Antenatal Clinic (Thursday mornings)

INFORMATION-GIVING DURING PREGNANCY

All women should be provided with accurate and accessible information about the risks associated with obesity in pregnancy and how they may be minimised. They should also have the opportunity to discuss this information.

This information is found in “Managing your weight in pregnancy” (Tommy’s https://www.tommys.org/pregnancy-information/im-pregnant/weight-management-pregnancy )

All women with BMI ≥ 40 must be given an Anaesthetic information leaflet. This must be documented in the notes.

RISK ASSESSMENT

Each ward should have a Resource Folder entitled Pressure Area Care Equipment Provision with details of weight limits for beds and information about sourcing additional equipment if required.

THROMBOPROPHYLAXIS

All women should be assessed at their first antenatal visit and throughout pregnancy for the risk of thromboembolism in accordance with the NBT VTE guideline.

All women requiring pharmacological thromboprophylaxis should be prescribed doses appropriate for maternal weight (see NBT VTE antenatal and postnatal risk assessment forms).

SURVEILLANCE AND SCREENING

An appropriate size of arm cuff should be used for blood pressure measurements taken at the booking visit and all subsequent antenatal consultations

Women with BMI ≥ 35 have an increased risk of pre-eclampsia and should be risk assessed as per below. If >1 high risk factor or >2 moderate risk factors, advise the woman to take 150mg aspirin OD taken in the evening from 12/40 until 36/40

Risk level Risk factors (please tick)

High □ Hypertensive disease during a previous

pregnancy

□ Chronic kidney disease

□ Autoimmune disease such as systemic lupus

erythematosus or antiphospholipid syndrome

□ Previous AKI

□ Type 1 or type 2 diabetes

□ Chronic hypertension

□ Confirmed placental dysfunction found on histology from

previous pregnancy

□ Confirmed fetal growth restriction in a previous pregnancy

□ Previous fetal loss over 20/40

Moderate □ First pregnancy

□ Aspirin taken during a previous pregnancy

□ Age 40 years or older at booking

□ Pregnancy interval of more than 10 years

□ Multiple Pregnancy

□ BMI 35kg/m2 or more at first visit

□ Family history of pre-eclampsia in a first degree relative

https://www.tommys.org/pregnancy-information/im-pregnant/weight-management-pregnancy


6

All women with BMI ≥ 40 should be prescribed oral Aspirin tablets 150mg daily (Women,

who need to take Aspirin 150mgs in pregnancy, should be advised to take it from 12 weeks

gestation, in the evening and to stop at 36 weeks gestation.

All women with BMI ≥ 30 should be screened for gestational diabetes o 2 hour 75g glucose tolerance test at 24-28 weeks

ULTRASOUND

All women with BMI ≥ 30 should have a dating scan

Anomaly scan- potential limitations should be explained

Growth scan at 28, 34 and 38 weeks if BMI ≥ 40 as per SGA GL. DIETICIAN REFERRAL

Consider for women with BMI ≥ 40 to provide advice regarding a calorie-controlled diet and avoidance of further weight gain.

ANAESTHETIC REFERRAL

Anaesthetic care pathway should be completed as appropriate

Some women with BMI ≥ 40 may need an antenatal consultation if there are relevant co-morbidities

Women with a BMI ≥ 40 but <50 should be seen by an anaesthetist on admission in labour.

Women with a BMI ≥ 50 should have an antenatal consultation with an obstetric anaesthetist so that potential difficulties with venous access, regional or general anaesthesia can be identified. An anaesthetic management plan for labour and delivery should be discussed and documented in the medical records.

PLANNING BIRTH

Women with BMI ≥ 30 should have an informed discussion antenatally about possible intrapartum complications associated with a high BMI (slow labour progression, shoulder dystocia, emergency caesarean section and postpartum haemorrhage) and management strategies considered.

If elective birth is planned the delivery suite manager, theatre and anaesthetic teams should be informed. Additional staffing levels may be necessary and the general surgeons may need to be involved.

3. Intrapartum Care

Women with a BMI ≥40 should give birth in a consultant-led obstetric unit with appropriate neonatal services.

Birth suite – the cut off for the Birth Suite is BMI 39.9 at any stage during pregnancy.

Inform duty anaesthetist when a women with BMI ≥ 40 is admitted to the delivery suite

Consider early placement of an epidural catheter if BMI ≥ 40 and no contraindications.

Women with BMI ≥ 40 in established labour should have o Continuous monitoring

7

o Venous access o Ranitidin six-hourly o Isotonic drinks or clear fluids. Avoid food and fizzy drinks.

Consider a Fetal Scalp Electrode (FSE) to improve the quality of the cardiotocograph (CTG) as fetal monitoring can be technically difficult and challenging.

Women with a BMI > 40 should have (follow hyperlink) skin care bundle completed when admitted.

BIRTH

Encourage normal birth

If available, an electric delivery bed should be used in labour.

A senior obstetrician and an anaesthetist should be informed and available for care of women with BMI ≥ 40 during labour and birth, including attending if required for any operative vaginal or abdominal delivery.

If Caesarean Section is required for BMI ≥ 50: o Inform Consultant Obstetrician and senior Anaesthetist o Ensure the operating table can withstand the extra weight (362kg limit).

Extensions to the operating bed are available in the theatre PREP room. o A Neonatologist should also be present for delivery. o Consider whether additional assistants are required to ensure safe access to

the uterus. o Pfannenstiel incision (evidence-based guidance is required on optimal

caesarean section technique for women with obesity in pregnancy) o Suturing of subcutaneous tissue space should be carried out if more than 2cm

subcutaneous fat. o Consider involvement of the general surgeons if there is a large abdominal

apron and any special equipment that may be needed. THIRD STAGE

Active management of third stage should be recommended for all women regardless of BMI.

3. Postnatal Care

THROMBOPROPHYLAXIS

All women should have postnatal assessment for risk of thromboembolism in accordance with NBT Risk Assessment forms.

Women with BMI ≥ 30 should be encouraged to mobilise as early as practicable.

Women with a BMI ≥ 40 should be offered postnatal thromboprophylaxis regardless of their mode of delivery (as per NBT postnatal Risk Assessment form).

BREASTFEEDING

Obesity is associated with low breastfeeding initiation and maintenance rates. Specialist advice and support should be offered.

CONTRACEPTION

Advise parenteral progesterone-based contraceptive.

http://webmasters-intranet73/wch/maternity/Maternity%20Guidelines/Maternity%20Pressure%20Ulcer%20Risk%20Assessment.pdf

8

ONGOING CARE

If gestational diabetes was diagnosed, appropriate follow-up with GP: o Fasting glucose 6 weeks after giving birth o Regular GP follow-up to screen for development of type 2 diabetes and cardio-

metabolic risk factors.

WOMEN WITH GASTRIC BANDS

Referral to the combined Consultant-led Endocrine Antenatal clinic (Thurs mornings) is indicated and additional growth scans will normally be required

Gastric bands should be released during pregnancy to allow optimal nutrition

Nutritional advice and supplementation should be provided

Gastric bands can be re-inflated once breastfeeding is complete or bottle-feeding is commenced.

Auditable Standards

An audit will be undertaken at least every three years which will audit compliance with this guideline. Where NICE Clinical guidelines exist, the NICE audit support tool will be utilised to measure against standards set. The audit will be presented at the divisional audit meeting following which an action plan will be formulated to correct any deficiencies identified and a date for re-audit planned. The implementation programme of the action plan will be reviewed 6 months after the presentation.

References

RCOG/CEMACE Joint Guideline: Management of women with obesity in pregnancy. March 2010.

Saravanakumar K, Rao SG, Cooper GM. Obesity and obstetric anaesthesia. Anaesthesia.2006Jan; 61(1): 36-48. Cedergren MI. Maternal Morbid Obesity and the Risk of Adverse Pregnancy Outcome.ObstetGynecol.Vol.103, No.2, Feb 2004. Sebire NJ, Jolly M, Harris JP, Wadsworth J, Joffe M, Beard RW, Regan L, Robinson S. Maternal Obesity and Pregnancy Outcome. Int J Obes Relat Metab Disord. Aug 2001, vol.25, no.8, p1175-82. Confidential Enquiry into Maternity and Child Health (2004) Why Mothers’ die 2000-2002. London:RCOG Press. Available at www.cemach.org.uk Confidential Enquiry into Maternity and Child Health (2007) Saving mothers’ lives: Reviewing maternal deaths to make motherhood safer-2003-2005. London CEMACH. London:RCOG Press. Available at www.cemach.org.uk Houston MC, Raynor BD. Postoperative morbidity in the morbidly obese parturient woman: supraumbilical and low transverse abdominal approaches. Am J Obstet Gynecol. 2000 May; 182(5):1033-5. International Association for the Study of obesity. Press Release Mar 2003. NICE Technology Appraisal Guideline – No 24. Guidance on the use of debriding agents and specialist wound care for difficult to heal surgical wounds. April 2001.

9

Gupta S. Obesity and Female hormones. The Obstetrician & Gynaecologist 2006; 8:26-31. RCOG Green Top Guideline No.42. Shoulder Dystocia. Dec 2005 NICE AN Care Guidelines (2008) NICE Intrapartum Care for healthy women and babies, Clinical Guidance (CG190) February 2018

FACILITIES AND EQUIPMENT

North Bristol Equipment Library Managed by Huntleigh Healthcare

The Equipment Library service provides the following:

Dynamic (Air) Mattress for loan

Dynamic Seat Cushion for loan

Maintenance & reports of all Faults with a Bed

Foam Mattress maintenance The aim of the service is to provide clean and safety electrical tested equipment for all users. The equipment that is loaned should ONLY be used for 1 patient to stop the spread of infection.

The service is managed by Huntleigh Healthcare Monday – Friday (9am – 5pm)

Out of hours service is covered by the Clinical Site Team.

Contact details Equipment Library (Frenchay) X (78) 2703 Southmead pager 07699 708182 Frenchay pager 07699 708181 Clinical Nurse Advisor 07780 955454 Bleep (Wed – Fri only) 9312 Tissue Viability X (77) 6170 Clinical Site Team X (77) 6199 X (77) 2123 Bleep 9147

10

Weight limit of beds in maternity: If women fall outside this weight please ensure equipment is ordered Delivery Beds – 35 stone (222 kgs) Theatre operating bed – 57 stone (362 kgs) Ward beds – 42 stone (267 kgs)

11

Care Of Women in the community with BMI ≥ 30 and <40 at booking in pregnancy Booking Visit/first consultant visit

Nutritional advice & advice re safety of weight loss if BMI >35. Direct to the Pregnancy App concerning healthy pregnancy and weight management and Tommy’s website: https://www.tommys.org/pregnancy-information/im-pregnant/weight-management-pregnancy

Folic Acid 5mg until 13 weeks

Vit D 10 mcg pregnancy & breast feeding (pregnacare or healthy start vitamins)

If BMI >35 and additional risk factors (as p14 in handheld notes) recommend 150mg aspirin daily from 12 weeks until 36 weeks

Thromboprophylaxis assessment as per guideline.

Record BMI Discussion of increased risks in pregnancy :

miscarriage

gestational diabetes,

pre-eclampsia

Venous thromboembolism

induced labour

caesarean section

anaesthetic complications

wound infections

stillbirth

congenital anomalies

prematurity

macrosomia

neonatal death.

developing obesity and metabolic disorders in childhood

(see guideline re odds ratios)

Large cuff for BP measurement

Date Signature

10-12 weeks Dating Scan 20 weeks Anomaly scan 24-25weeks BP + urinalysis 27-28 weeks BP + urinalysis

Oral Glucose Tolerance Test (OGTT)

30 weeks BP + urinalysis 32 weeks BP + urinalysis 34 weeks BP + urinalysis

Weight - Recalculate BMI if ≥ 40 refer to consultant care and follow SGA Guideline

36 weeks BP + Urinalysis

Reassess thromboprophylaxis risk as per guideline

38 weeks BP and urinalsys Intrapartum Active management of 3rd stage Post natal Reassess thromboprophylaxis risk as per

guideline

If Gestational diabetes fasting glucose 6/ 52 post natal & F/U in diabetic ANC if abnormal

Advice re diet and nutrition



12

Contraceptive advice Reference: Joint RCOG/CEMACE Guideline: Management of women with obesity in pregnancy. March 2010.

13

Care Of Women with BMI ≥ 40 and <50 at booking in pregnancy

Date Signature

Booking Visit/first consultant visit

Consultant led care

Nutritional advice & advice re safety of weight loss. Give leaflet “Managing your weight in pregnancy”


Vit D 10 mcg pregnancy & breast feeding (pregnacare or healthy start vitamins)If additional risk factors (as p14 in handheld notes) recommend 150mg aspirin daily from 12 weeks until 36 weeks Thromboprophylaxis assessment as per guideline.


miscarriage


pre-eclampsia


induced labour

caesarean section


wound infections

stillbirth


prematurity

macrosomia

neonatal death.




Complete anaesthetic care plan below

10-12 weeks Dating Scan

20 weeks Anomaly scan

24-25weeks BP + urinalysis

27-28 weeks BP + urinalysis

Oral Glucose Tolerance Test (OGTT)

28 weeks Growth scan

30 weeks BP + urinalysis



Weight - If >220kg please alert CDS manager for manual handling assessment

Growth scan as per SGA GL

Mode of delivery assessment and information re increased risks during labour and delivery


Reassess thromboprophylaxis risk as

14

per guideline


Growth scan as per SGA GL

Intrapartum Complete skin bundle

Venous access/ ranitidine 6hrly in labour

Review by anaesthetist in labour

Senior obstetrician and anaesthetist for operative delivery

Active management of 3rd stage

Continuous EFM

Post natal Reassess thromboprophylaxis risk as per guideline

If Gestational diabetes fasting glucose 6/52 post natal & F/U in diabetic ANC if abnormal


Contraceptive advice

*Age > 40yrs /first pregnancy/ /family history PET/multiple pregnancy Reference: Joint RCOG/CEMACE Guideline: Management of women with obesity in pregnancy. March 2010

15

Raised BMI: Anaesthetic plan BMI ≥ 50 at any time in pregnancy: Yes No If Yes refer to Anaesthetic ANC for Consultant Anaesthetic review Seen in ANC by Consultant Anaesthetist: Yes No If Yes: see specific anaesthetic note BMI >40 <50: Yes No 1. Anaesthetic ‘raised BMI information leaflet’ given antenatally? Yes No

Signed (Midwife or obstetrician) when leaflet given ………………………… 2. Plan in labour: a) No food b) Clear fluids or isotonic sports drinks only c) Regular ranitidine d) Consider early epidural to allow rapid top up for operative delivery if necessary e) Anaesthetic Review on arrival in labour: Comments by anaesthetist (re: airway etc): Discussed with senior anaesthetic colleague? Yes No Signed (Anaesthetist seeing woman in labour)……………………………..

16

Care Of Women with BMI ≥50 at booking in pregnancy

Date Signature

Booking Visit/first consultant visit

Consultant led care in Endocrine ANC

Advice re nutrition & safety of weight loss give leaflet “Managing your weight in pregnancy”


Vit D 10 mcg pregnancy & breast feeding (Pregnacare or healthy start vitamins)

If additional risk factors (as p14 in handheld notes) recommend 150mg aspirin daily from 12 weeks until 36 weeks Thromboprophylaxis assessment as per guideline.


miscarriage


pre-eclampsia


induced labour

caesarean section


wound infections

stillbirth


prematurity

macrosomia

neonatal death.




Anaesthetic referral & complete care plan below

12 weeks Dating Scan

18- 21 week Anomaly scan

24-25 week BP + urinalysis

27-28 week BP + urinalysis Oral Glucose Tolerance Test (OGTT)

28 weeks Growth scan




Weight - If >220kg please alert CDS manager for manual handling assessment

Growth scan

Consultant team review in ANC. Mode of delivery assessment and information re increased risks during labour and delivery

If > 220kg alert CDS manager for manual handling assessment

Document individualised labour care plan

ECG performed

17


VTE re-assessment


Growth USS

Intrapartum Complete skin bundle

Venous access/Ranitidine 6hrly in labour

Review by anaesthetist in labour

Senior obstetrician and anaesthetist for operative delivery

Consultant present for LSCS

Active management of 3rd stage

Continuous EFM

Post natal Reassess thromboprophylaxis risk

If gestational diabetes fasting glucose 6/ 52 post natal & F/U in diabetic ANC if abnormal


Contraceptive advice

Reference: Joint RCOG/CEMACE Guideline: Management of women with obesity in pregnancy. March 2010

18

Raised BMI: Anaesthetic plan BMI ≥ 50 at any time in pregnancy: Yes No If Yes refer to Anaesthetic ANC for Consultant Anaesthetic review Seen in ANC by Consultant Anaesthetist: Yes No If Yes: see specific anaesthetic note BMI >40 <50: Yes No 1. Anaesthetic ‘raised BMI information leaflet’ given antenatally? Yes No

Signed (Midwife or obstetrician) when leaflet given ………………………… 2. Plan in labour: a) No food b) Clear fluids or isotonic sports drinks only c) Regular ranitidine d) Consider early epidural to allow rapid top up for operative delivery if necessary e) Anaesthetic Review on arrival in labour: Comments by anaesthetist (re: airway etc): Discussed with senior anaesthetic colleague? Yes No Signed (Anaesthetist seeing woman in labour)……………………….

19

Surgical and anaesthetic care Pathway for women with BMI > 50

Surgical considerations:

Women who have a BMI > 50 should have a subumbilical midline incision rather than a pfannenstiel incision to reduce their risk of postoperative wound infection.

An O ring should be used in these women to optimise access and views.

Drains should not be inserted routinely. If a drain is absolutely necessary then a Robinson drain should be used within the abdominal cavity, not in the fat layer. Under no circumstances should a Redivac drain be used.

For a subumbilical incision, loop PDS should be used to close the rectus sheath and peritoneum in a mass closure.

The fat layer should be closed with continuous vicryl to close the dead space.

Staples should be used to close the skin. They should be left in for 10 days, at which time she should come back for a wound review and removal of clips by a registrar.

If the woman has a very infected apron then consider not closing above the rectus sheath and applying a VAC dressing.

Postnatal care

Dressings should be left in place longer for women with a BMI > 50. In order to still allow monitoring of the wound, these should be transparent.

Wound infections are usually seen around 10 days post-operatively and therefore these women should have a registrar review at 10 days.

All women should be sent home with a patient information leaflet to include advice on wound care and what “red flag” symptoms they should look out for and what to do, to ensure early treatment of any wound infection.

Women with a BMI > 50 should have IV Cefuroxime and PR Metronidazole prior to knife to skin in line with the normal caesarean section policy. They should not have prophylactic courses of oral antibiotics.

Anaesthetic considerations:

Senior anaesthetist should be involved and two anaesthetists present if possible

Combined spinal epidural for elective CS in case surgery is prolonged. Consider flushing epidural catheter with 1ml 0.9% saline once placed to prevent blockage. Start topping up early if surgery is looking like it might be prolonged.

Consider use of ultrasound guidance in placement of CSE.

Secure epidural catheter (of CSE) with dedicated fixation device e.g. Lockit. Ensure ODP / anaesthetic nurse has this and the tegaderm dressing / cut mefix ready

If working epidural in situ for labour use an epidural top up for an emergency CS

For a general anaesthetic:

Consider increasing dose of suxamethonium (1-1.5mg/kg to a max of 200mg).

To aid rapid recovery use desflurane or sevoflurane rather than isoflurane for maintenance of general anaesthesia.

Apply at least 4cm H20 PEEP to prevent small airway closure during GA.

Extubate fully awake and sitting up.

20

Consider Arterial line if difficulties with NIBP anticipated (if there is time, check use of non-invasive BP monitoring before starting regional anaesthesia.

Consider 2nd IV cannula

Positioning:

HELP pillow for GAs

Consider using HELP pillow for regional anaesthesia as well (NB operating table may need to be tilted in Trendelenberg after insertion of the CSE to achieved desired height of block). The woman needs to lie directly on the pillow, without a sheet underneath to prevent slipping. If the woman is awake, consider using a normal pillow under her head rather than the HELP head support. Use red arm pads and leg support.

Lock arm boards onto operating table for added width or lock right side onto table and use left arm board out to side to keep this arm out for stability in left tilt.

Hover mattress positioned so available for transfer at the end

Warmed fluids with blood giving set. Have syntocinon infusion (40u in 500mls 0.9% saline) ready if carbetocin not available

Consider cell salvage

21

Maternal and fetal risks in women with a BMI ≥30 kg/m2 compared to women with a healthy BMI Risk Study Pop. Odds ratio

[95%Confidence interval]*

Gestational diabetes

NW Thames 1989 – 97 1

Aberdeen 1976 – 2005 2 287213 24241

3.6 [3.3-4.0] a

2.4 [2.2-2.7]

Hypertensive disorders NW Thames 1989 – 97 1

Aberdeen 1976 – 2005 2

287213 24241

2.1[1.9-2.5] a

3.3 [2.7-3.9]


Denmark 1980 – 2001 3 71729 9.7 [3.1-30.8]

Slower labour progress 4 – 10cm

USA 1995 – 2002 4 612 7 versus 5.4 hrs p<0.001

Caesarean

Meta-analysis of 33 studies 2.1 [1.9-2.3]

Emergency caesarean NW Thames 1989 – 97 1

Cardiff 1990 – 99 5

287213 8350

1.8 [1.7-1.9] 2.0 [1.2-3.5]

Postpartum Haemorrhage

NW Thames 1989 – 97 1

Aberdeen 1976 – 2005 2

287213 24241

1.4 [1.2-1.6] a

2.3 [2.1-2.6]

Wound infection

NW Thames 1989 – 97

287213 2.24 [1.91-2.64] a

Birth defects

Australia

11252 1.6 [1.0-2.5]

Prematurity Aberdeen 1976 – 2005 Australia 1998 – 2002

24241 11252

1.2 [1.1-1.4] 1.2 [0.8-1.7]

Macrosomia NW Thames 1989 – 97 1

Sweden 1992 – 2001 287213 805275

2.4 [2.2-2.5] a

3.1 [3.0-3.3]

Shoulder dystocia Sweden 1992-2001 7

Cardiff 1990 – 99 805275 8350

3.14 [1.86-5.31] b

2.9 [1.4-5.8]

Admission to NNU NW Thames 1989 – 97 1

Cardiff 1990 – 99 5

287213 8350

1.3 [1.3-1.4] a

1.5 [1.1-2.3]

Stillbirth

Meta-analysis of 9 studies

2.1 [1.5-2.7]

Neonatal death

Denmark 1989 – 96

24505 2.6 [1.2-5.8]

.

health: n · women with bmi ≥ 35 have an increased risk of pre-eclampsia and should be risk...

Documents