Individualizing Care for the Obese Patient:

Ideas, Recommendations and Tools for the

Bedside Nurse

Margie Bridges, DNP, ARNP-BC, RNC-OB

Michele Kulhanek, MSN, RNC-OB, C-EFM

Disclosure

We have potential or significant conflicts of interest exist in the

program development and/or content of the presentation.

Objectives

❏ Identify challenges and potential solutions

❏ Recognize social bias and discrimination

❏ Establish models of care that address Perinatal Obesity ❏ Provide a safe and therapeutic environment of care for patients

and staff

Think Tool Kit!

The World Health Organization (WHO) describes obesity as

“one of the most blatantly visible, yet neglected, public health

problems that threatens to overwhelm both more and less

developed countries”

Meet Mary

❏ 35 year old, G1P0

❏ History

❏ Comorbidities

❏ BMI 50

❏ PROM

❏ Patient is admitted

Risk Factor Review for Mary ❏ Miscarriage

❏ Infertility

❏ Congenital anomalies

❏ Weight Bias/Stigma

❏ Diabetes

❏ CVD Hypertension

❏ Labor Dystocia

❏ Macrosomia

❏ OVD (2x)

❏ Shoulder Dystocia (2-4x)

❏ Emergency C/S (2x)

❏ Birth Trauma

❏ Anesthesia Difficulties

❏ Infection

❏ VTE

❏ Breastfeeding Challenges

❏ Stillbirth (40%)

❏ Death ACOG Practice Bulletin (2015)

Sources of Weight Bias & Stigma

The Patient Experience

❏ Negative attitudes and attributes

❏ Can be subtle or direct

❏ Implicit anti-fat bias

❏ Derogatory humor

Gudzune et. al. (2013). Physicians build less rapport with obese patients

Puhl, R.M & Heuer, C. (2009). The stigma of Obesity: A review and update

Sources of Weight Bias & Stigma

The Nurse Experience

❏ Workload: Labor intensive workload

❏ Fear of injuries

❏ High probability of a C/S

❏ Inadequacy and powerlessness

Providing Respectful Care

RESPECT MODEL

❏ R-Rapport

❏ E-Environment

❏ S-Safety

❏ P-Privacy

❏ E-Encouragement

❏ C-Caring/Compassion

❏ T-Tact

SIZE FRIENDLY CARE

Belly-Spring, S. M. (2008). R-E-S-P-E-C-T: A model for the sensitive treatment of the Bariatric Patient

What is your Gut Reaction to these

photos?

http://www.youtube.com/watch/v=77iskJg4Qsg

How about

these

photos?

Pintrest Huge pregnant bellly-1

The TEAM I Lost the

Significant

Other and

Family

Surgica

l Tech

OBGYN

Dietician

Anesthesi

a

PT/OT

Mary

RT

Nurse

Lift

Team

Charg

e

Nurse

Lactatio

n

Doula

How do we address Mary’s Intrapartum Risks?n

TIME

❏ Timing of Birth

❏ Labor

❏ Positioning

❏ Epidural

❏ Getting to the O.R.

STAFF

❏ Staffing Ratio

❏ Doula support

· Moussa et al. (2016). Obesity epidemic: impact from preconception to postpartum· Schuster et. al. (2016). AWHONN Guidelines for professional registered nurse staffing for perinatal units (2010) Guidelines for Perinatal Care (2017). The effect of MFM obesity protocol on cesarean delivery rates. AJOG James & Maher.(2009), MCN·

What’s in your toolbox?

❏ Scale

❏ Resus equipment

❏ BP cuffs

❏ Vein imaging

❏ Early IV access/2 IVs

❏ Larger needles for IM

injections/venipuncture

What’s in your toolbox?

❏ Belly bands, belts and fetal

monitoring

❏ Bedside US

❏ Traction bar, hover mat

❏ Pillows, wedges, draw sheets

❏ Extra personnel

❏ Skin assessment

Toolbox Essentials

❏ Birthing ball weight limits

❏ Peanut ball usage

❏ Bariatric bed

❏ OR bed with extenders

❏ Pathway to the OR

❏ Other items

❏ Resource binder

Resource Binder

1. Consultations

2. Equipment 3. Ordering

4. Weight limits

5. Protocol/Policies 6. VTE prophylaxis

7. Care Model

Managing Labor

❏ Passage: Soft tissue labor

dystocia

❏ Passenger: Fetal

macrosomia/GDM. Fat Vagina

Theory(?)

❏ Power: Myometrial

dysfunction/Impaired uterine

forces

Kominiarek et al.(2011). AJOG, Fyfe et al. (2011), Verdiales, (2009). Journal of Perinatal Medicine Zhang et al. (2007),Cedergren, (2010).Eur. Journal of OBGYN Reprod. & ,Garabediam et al. (2011)

Induction of Labor

Takes longer than spontaneous labor

that is already Longer

57 % : Cervical ripening Failure

80% Induction rate failure: Obese III

with macrosomia nulliparous

Require higher doses of Oxytocin

Gauthieret et al. (2011). Obesity and cervical ripening failure risk. Journal of Maternal-

Fetal Medicine

Wolfe, et al (2011). The effect of maternal obesity on the rate of failed induction of labor.

AJOG

Managing Labor

❏ Assistance from others

❏ Determining fetal station

❏ Early Epidural placement

❏ Use of “Event Button”

❏ Consider internal monitors

❏ Wireless monitoring

Documentation Tips

“Nurse at bedside, fetal heart rate appears sketchy; toco not picking up contractions; patient requests pain medication; midwife called for orders”

“Nurse at bedside; unable to

interpret fetal heart rate data due to

non-contiguous tracing related to

maternal body habitus; firm

contractions palpable every 2-3

minutes; monitors readjusted;

patient requests pain medication,

pain scale 7/10; Midwife Duncan

called for pain medication orders

and fetal spiral electrode/intrauterine

pressure catheter placement”

Cypher, R.L., (2018) Electronic Fetal Monitoring Documentation, Journal of

Perinatal & Neonatal Nursing, Vol 32, No 1, 24-33

Mary Needs a Cesarean Birth

❏ Many hands, additional help/time to get ready

❏ What OR?

❏ Blood Typed and Crossmatched

❏ Aspiration Risk

❏ Re-check epidural placement

❏ Monitoring

❏ Risk of Infection

❏ VTE prophylaxis

❏ Prep

❏ Decision to incision/skin incision to delivery

❏ Operative time >2hrs

Gunatilake et al.(2010). AJOG

Surgical Considerations and Care

❏ Pico/pressure dressings

❏ Wound vacuum

❏ Silver dressings

❏ Foley/Perineal care

❏ Traxi or other products

❏ Retractors

❏ Different suture/subcutaneous layer

Tools for C-sections

Immediate Recovery Postpartum Care

❏ Increased risk of PPH

❏ VTE Prophylaxis

❏ Respiratory Oxygenation; use of incentive Spirometer, pulse

ox, sedation scoring(narcotics)

❏ Rass/Paseo

Post-op Recovery Care

❏ Wound infections/breakdown

❏ Endometriosis/sepsis

❏ Clotting Disorder VTE

❏ PPH

❏ Respiratory/airway complications

❏ Prolonged Hospitalization

❏ Emergency department visit

❏ Readmission

⅓ of maternal

deaths associated with

obesity complications...

many following C/S

birth

Obesity in Pregnancy: Committee Opinion No. 549 (ACOG). Obstetrics and Gynecology (2012)

Tita ATN et al. Adjunctive azithromycin prophylaxis for cesarean delivery. NEJM. (2016)

Post-operative Care incisional Care

❏ Post cesarean wound infection doubles with every five-unit increment of BMI

❏ Removal of staples or suture?

❏ Abdominal binder

❏ Wound care

❏ Incisional check 1-2 weeks

Gunatilake et al.(2010). AJOG

Postpartum VTE

Hypercoagulability

Vascular Damage Circulatory Stasis

Surgery, Infection, Pregnancy/Postpartum,

Dehydration

Indwelling catheters,

Venipuncture, Diseases Immobility, Pregnancy,

Obesity

Blood

Vessel Flow

Virchow’s Triad Improving Health Care Response to Maternal Venous

Thromboembolism: A California Quality Improvement Toolkit,

(2018). CMQCC

Postpartum Care

❏ Postoperative pain

❏ Safe sleep for baby

❏ Breastfeeding

Long-Term

❏ Reduced duration of Lactation

❏ Postpartum Weight Retention

❏ PMAD

❏ Testing for DM

❏ Follow-up for HTN

❏ Contraception- preconception counseling

❏ Referrals- weight reduction, endocrine

Gunatilake et al.(2010). AJOG

What Next?...

Mary:

Decreased VBAC success

Weight loss and next pregnancy

Bariatric Surgery

Health Care team:

❏ Practice Drills for using and moving special equipment

❏ Resource Binder

❏ Reflect on bias and stigma- Practice Empathy

❏ _________

QUESTIONS…...

References ACOG Committee Opinion #315: Obesity in Pregnancy. (2005). Obstetrics & Gynecology, 106(3), 671-675. doi:10.1097/00006250-200509000-00054

Allen, G. (2017). Evidence appraisal of Tita ATN, Szychow ski JM, Boggess K, et al. Adjunctive azithromycin prophylaxis for cesarean delivery. AORN

Journal, 105(1), 117-122. doi:10.1016/j.aorn.2016.11.014

Amicone, L., Tressler, T., Taboada, C., Martinez, F., & Wert, Y. (2015). OP17.11: The impact of maternal obesity on a maternal fetal-medicine off ice.

Ultrasound in Obstetrics & Gynecology, 46, 105-105. doi:10.1002/uog.15263

AWHONN Staff ing Survey. (2002). AWHONN Lifelines, 6(2), 160. doi:10.1111/j.1552-6356.2002.tb00058.x

Bejciy-Spring, S. M. (2008). R-E-S-P-E-C-T: A Model for the Sensitive Treatment of the Bariatric Patient. Bariatric Nursing and Surgical Patient Care, 3(1),

47-56. doi:10.1089/bar.2008.9991

Cedergren, M. I. (2009). Non-elective caesarean delivery due to ineffective uterine contractility or due to obstructed labour in relation to maternal body mass

index. European Journal of Obstetrics & Gynecology and Reproductive Biology, 145(2), 163-166. doi:10.1016/j.ejogrb.2009.05.022

Cypher, R. L. (2018). Electronic Fetal Monitoring Documentation. The Journal of Perinatal & Neonatal Nursing, 32(1), 24-33.

doi:10.1097/jpn.0000000000000299

Fyfe, E. M., Anderson, N. H., North, R. A., Chan, E. H., Taylor, R. S., Dekker, G. A., & McCow an, L. M. (2011). Risk of First-Stage and Second-Stage

Cesarean Delivery by Maternal Body Mass Index Among Nulliparous Women in Labor at Term. Obstetrics & Gynecology, 117(6), 1315-1322.

doi:10.1097/aog.0b013e318217922a

Gauthier, T., Mazeau, S., Dalmay, F., Eyraud, J., Catalan, C., Marin, B., & Aubard, Y. (2011). Obesity and cervical ripening failure risk. The Journal of

Maternal-Fetal & Neonatal Medicine, 25(3), 304-307. doi:10.3109/14767058.2011.575485

Gudzune, K. A., Beach, M. C., Roter, D. L., & Cooper, L. A. (2013). Physicians build less rapport w ith obese patients. Obesity, 21(10), 2146-2152.

doi:10.1002/oby.20384

Guidelines for Professional Registered Nurse Staff ing for Perinatal Units Executive Summary. (2011). Nursing for Women's Health, 15(1), 81-84.

doi:10.1111/j.1751-486x.2011.01603.x

Gunatilake, R. P., & Perlow , J. H. (2011). Obesity and pregnancy: clinical management of the obese gravida. American Journal of Obstetrics and

Gynecology, 204(2), 106-119. doi:10.1016/j.ajog.2010.10.002

In Kilpatrick, S. J., American Academy of Pediatrics,, & American College of Obstetricians and Gynecologists. (2017). Guidelines for perinatal care.

James, D. C., & Maher, M. A. (2009). Caring for the Extremely Obese Woman During Pregnancy and Birth. MCN, The American Journal of

Maternal/Child Nursing, 34(1), 24-30. doi:10.1097/01.nmc.0000343862.72237.62

Jie Zhang, Kendrick, A., Quenby, S., & Wray, S. (2007). Contractility and Calcium Signaling of Human Myometrium Are Profoundly Affected by

Cholesterol Manipulation: Implications for Labor? Reproductive Sciences, 14(5), 456-466. doi:10.1177/1933719107306229

Kominiarek, M. A., Zhang, J., VanVeldhuisen, P., Troendle, J., Beaver, J., & Hibbard, J. U. (2011). Contemporary labor patterns: the impact of

maternal body mass index. American Journal of Obstetrics and Gynecology, 205(3), 244.e1-244.e8. doi:10.1016/j.ajog.2011.06.014

Leddy, M. A., Pow er, M.L.,& Shulkin, J. (2008). The impact of maternal obesity on maternal and fetal health. Reviews in Obstetrics & Gynecology,

1(4), 170-178

Moussa, H. N., Alrais, M. A., Leon, M. G., Abbas, E. L., & Sibai, B. M. (2016). Obesity epidemic: impact from preconception to postpartum. Future

Science OA, 2(3), FSO137. doi:10.4155/fsoa-2016-0035

Puhl, R. M., & Heuer, C. A. (2009). The Stigma of Obesity: A Review and Update. Obesity, 17(5), 941-964. doi:10.1038/oby.2008.636

Schuster, M., Madueke-Laveaux, O. S., Mackeen, A. D., Feng, W., & Paglia, M. J. (2016). The effect of the MFM obesity protocol on cesarean

delivery rates. American Journal of Obstetrics and Gynecology, 215(4), 492.e1-492.e6. doi:10.1016/j.ajog.2016.05.005

Tita ATN et al. (2017). Adjunctive Azithromycin Prophylaxis for Cesarean Delivery. New England Journal of Medicine, 376(2), 181-182.

doi:10.1056/nejmc1614626

Wolfe, K. B., Rossi, R. A., & Warshak, C. R. (2012). The Effect of Maternal Obesity on the Rate of Failed Induction of Labor. Obstetric Anesthesia

Digest, 32(2), 96. doi:10.1097/01.aoa.0000414075.05312.64

Verdiales, M., Pacheco, C., & Cohen, W. R. (2009). The effect of maternal obesity on the course of labor. Journal of Perinatal Medicine, 37(6).

doi:10.1515/jpm.2009.110