Managing Labor and Delivery For your obese patient

Labor management decisions  Tension between  Hope for successful vaginal delivery and fear of emergency cesarean delivery  Avoidance 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  Diabetes  Monitoring  Insulin  Hypertension/preeclampsia  Magnesium  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 OutcomeTOLERCSOR 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 OutcomeFailedSuccessOR 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 size  Serial 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 available  Equipment check list  Identify roles for  Emergency cesarean  Shoulder dystocia

Elements of care plan  Lab: Type and screen, CBC  Secure IV access  Thromboprophylaxis  Maternal and fetal monitor  Continuous EFM, toco  BP cuffs  Glucometer

Other considerations  ? Postpone other elective patient care  Set expectations for labor progress  When to consider cesarean  When to consider (or not) operative vaginal delivery  Induction issues  Cervical ripeness criteria  Duration of ROM  Minimize length of hospitalization