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