Understanding and Caring for the Obese Woman during Childbirth
Valerie Huwe RNC-OB, MS, CNSPerinatal Outreach Educator
UCSF Benioff Children’s Hospital
September, 2018
Objectives
Discuss the impact of obesity on maternal health complications and associated neonatal risks
Explore the physical challenges nurses face when caring for an obese woman during childbirth
Highlight ways to provide: evidenced based, high quality, and safe care for obese women
World Wide Epidemic
Over 1 Billion adults are overweight
• 400 million are obese
66% (2/3) of U.S. Adults
50% of U.S. Women are either over weight or obese
prevalence for Black and Hispanic populations
with education and nulliparity
Fastest growing health problem in the U.S.
Disease of this Century!
Definitions: IOM 1990
Normal 18.5 - 24.9 kg/m2
Overweight 25 - 29.9 kg/m2
Obese ≥ 30 kg/m2
• Class I 30 – 34.9
• Class II 35 – 39.9
• Class III ≥ 40 (Morbid obesity)
• Super Obesity ≥ 50
ACOG, NIH, and WHO all use the same definitions
Obesity Trends* Among U.S. AdultsBRFSS, 1985
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14%
Behavioral Risk Factor Surveillance System
Obesity Trends* Among U.S. AdultsBRFSS, 1990
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14%
Obesity Trends* Among U.S. AdultsBRFSS, 1995
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14 % 15%–19%
Obesity Trends* Among U.S. AdultsBRFSS, 2000
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% ≥20%
Obesity Trends* Among U.S. AdultsBRFSS, 2005
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
Obesity Trends* Among U.S. AdultsBRFSS, 2010
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
Prevalence has doubled in the last 10 years
Associated Health Risks
Mace, H.S., et al., (2011) Anaesth Intensive care
Medical Complications of Obesity
Prevalence of Obesity for Women in the U.S. of Childbearing Age
Nearly 2/3 of Childbearing women in the US
• Overweight (BMI = 25-29.9 kg/m2)
or• Obese (BMI ≥ 30 kg/m2)
‒32% of women ages 20 to 44
• BMI ≥ 40 or BMI ≥ 35 with co-morbidities
‒Counseled for bariatric surgery
Impact of Obesity on the Physiology:Maternal Complications
Pregnancy
Blood Volume• 50%
Cardiac output• 50%
Pulmonary changes• FRC
• residual volume
Hypercoagulation
Endocrine
Inflammatory changes
Obesity BMI = demand
BMI = demand
25% supine position• resp rate• compliance
• V/P mismatch
Venous stasis
Insulin resistance
Vascular dysfunction
Marshall, N. E., (2012) Seminar in Reproductive Medicine
Obesity Risks in Pregnancy
Subfertility• Ovulatory dysfunction
Preterm birth
Pre E • Risk doubles with each
5-7 kg/m2
HTN
Cardiac disease
GDM
Multiple gestation
Congenital Malformations
Postterm pregnancy
Operative vaginal delivery
C/S
LGA
Prolonged labor
Labor augmentation
Early amniotomy
Stillbirth
UTI - risk 42 %
Thromboembolism
Obstructive sleep apnea
Maternal Pregnancy Labor
Subfertility PreeclampsiaRisk doubles each 5-7 kg/m2
Postterm/IOL
Ovulatory
dysfunction
GDM Early amniotomy
HTN Physiologic changes of
PregnancyCesarean Birth
Cardiac disease Multiple gestation PPH Blood
Diabetes Mellitus Congenital
Malformations
Infection
Obesity Risks
Obesity Pregnancy Complications
Gestational DM OR = 3.6, 95% CI: 3.3 - 4.0
Gestational HTN OR = 3.4, 95% CI: 2.0 - 5.7
Cesarean Section OR = 2.0, 95% CI: 1.3 –3.3
Postpartum Hemorrhage OR = 1.4, 95% CI: 1.3 – 1.5
Macrosomia OR = 2.1, 95% CI: 1.9 – 2.4
COMMITTEE OPINION .
Number 600 • June 2014 The American College ofObstetricians and Gynecologists
WOMEN’S HEALTH CARE PHYSICIANS
Acknowledge changing demographics
Fellows must be prepared for the future
• Obesity education: medical, cultural, and social issues
• Feel comfortable discussing obesity ethically and unbiased
• Benefit from multidisciplinary team approach
‒ Internists, surgeons, nutritionists, dietician, Mental Health Professional, community support for wt loss
Think of obesity as a modifiable risk factor like:
• Smoking, HTN, Hypercholesterolemia
ACOG Vol. 123, NO. 6, June 2014. Obstetrics & Gynecology
Antenatal Care
Nutrition
• Nutritionists – time intensive
• Monitor for ketonuria
Exercise barriers
‒ Motivation, physical limitations, time constraints
Fetal surveillance
• NST, BPP not proven to decrease stillbirth rate
Obese abdominal wall
• Body habitus contributes to difficult assessment
Yao, R., et. al., (2014) Am J. Obstet and Gynecol
Behavioral Health – the 5 “As”
Ask/Assess Ask permission before discussing weight
• non-judgmental. Screen for weight status, obesity-associated comorbid conditions and conditions that may interfere with weight loss, and patient interest in weight management.
Advise – on risks associated with obesity
• avoid “gloom and doom” and benefits associated with lower weight gain/improved diet (eg GDM risk)
Agree – In discussion with provider, patient chooses and sets goals for behavior change
• cutting out sugar-sweetened drinks
Assist – suggest resources (apps, online tools), provide support
Arrange – F/U visits. A consistent predictor of weight loss progress is having regular, ongoing interaction with provider or group.
Pregnancy after Bariatric Surgery
Rate of bariatric surgery BMI 40 3 Types
Restrictive Surgery Malabsorbtive surgery
Post-op fertility conflicting
Vitamin and mineral deficiencies
Harris, A., et.al., (2010) JMWH
Delay pregnancy 12 -18 months
Pregnancy after Bariatric Surgery
3rd TypeSerious surgical complications with ALL
• N/V abd pain
‒Band erosion/migration‒anastomotic leaks‒Bowel obstruction
Bariatric Surgical consult
↓ risk of PreE, GDM, and macrosomia
Badreldin, N, et. al., Volume 71, 6 OB GYN SURVEY. 2016
Feelings of Obese Women
Negative perception re obesity
• Stigma
• Dismissed feelings – not quite human
Defensive and ashamed
Providers report discomfort discussing obesity
Obese women want
• Supportive non-judgmental, clear and concise care
• Keep positive, open approach
Yao, R., et. al., (2014) Am J. Obstet and Gynecol
Antenatal Care
Provider Patient Discussion
Potential risks
• Availability of hydrotherapy water labor or birth
• Need for internal fetal monitoring
• Antithromboembolic precautions
‒Early ambulation – Anticoagulation – SCV
• Anesthesia Consult
‒Limitation on emergency birth
Yao, R., et. al., (2014) Am J. Obstet and Gynecol
Maternal Pregnancy Labor
Obesity Multiparity Cesarean Birth
Smoking Preeclampsia PPH Blood
Hx of VTE Physiologic changes of
PregnancyInfection
Diabetes Immobilization
Age > 35 years
Risk Factors for DVT
Recommendations for total and rate of weight gain during pregnancy prepregnancy BMIa
Adapted from National Research Counsil
Kriebs (2014) Am J. JPNN
Fetal Risks
Structural birth defects
• Neural tube : spina bifida, septal anomalies, cleft palatecardiac defects, anorectal atresia, limb reduction defects,omphalocele
Prematurity
Macrosomia
Birth Injury
• Shoulder dystocia
NICU admissions
Yao, R., et. al., (2014) Am J. Obstet and Gynecol
Childhood Risks
Fetal Programming
• Obesity
• Metabolic Syndrome
• Cardiac disease (childhood)
Asthma
Autism spectrum disorder
ADHD
Yao, R., et. al., (2014) Am J. Obstet and Gynecol
Induction of Labor: Bishop Score < 6
• Misoprostol PGE1
‒ $23.00/tablet
‒ N = 297
‒ C/S = 116 (39.1)
• Cervidil PGE2
‒ $ 280.00/insert
‒ N = 178
‒ C/S 137 (51.3)
Suidan, R., et. al., (2014) Am J Perinatology
Higher BMI = Higher PGE2 levels
PGE2 had reduced action in obese women compared to non-obese women
Obese women were less sensitive to PGE2
The Effects of Obesity on the First Stage of Labor
Norman, S. M., Tuuli, M. G., Odibo, A. O., Caughey, A. B., Roehl, K. A., & Cahill, A. G. (2012). The effects
of obesity on the first stage of labor. Obstetrics & Gynecology, 120(1), 130-135.
The Effects of Obesity on the First Stage of Labor
Norman, S. M., Tuuli, M. G., Odibo, A. O., Caughey, A. B., Roehl, K. A., & Cahill, A. G. (2012). The effects
of obesity on the first stage of labor. Obstetrics & Gynecology, 120(1), 130-135.
Obesity and Dystocia
Theory: Soft tissue obstruction causation
Theory: obesity alters physiology
• Myometrial cells contract less efficiently
‒ Leptin
‒ Cholesterol
2nd Stage same as normal weight women
Zhang J. et. al., BJOG (2007) ;
Obesity and Intrapartum Interventions
Induction of Labor
Early labor admission
to have successful cervical ripening
Oxytocin augmentation
Early amniotomy (AROM)
Epidural anesthesia
Less likelihood of assisted vaginal birth
Pevzner, L., et. al., Obstet Gynecol. (2009)
Obesity and the neonate
Overweight and obese women
• More likely to gain more than recommended by IOM
compared to normal weight women
Slightly larger neonates (Controlled for DM)
Nursing Care
1:1 Nurse patient ratio• Maintain continuous FHR tracing
• Continuous bedside attention
• Assistance with movement
• Assistance with self care
AWHONN Staffing Guidelines (2010)
Safety concerns for nurses
Air pal – medical grade aerobedCeiling hoist – lifts patient from one position to anotherHover MatCable length of FSE
IUPC may register
elevated resting tone It’s unclear what is
normal resting tone for obese women
Meet Jaxanne
36 yo G2P0 @ 39+1
BMI 75 (5’4’’ 462 lbs.)
IOL GDM A2 Insulin
FHR: BL 130 Accelerations present
VE 1/60/-2 (BS =4)
08:30 Misoprostol 25 micrograms (vaginal)
14:00 Epidural is placed – not bolused
14:30 2nd Misoprostol placed
18:00 clear liquid dinner
19:00 3rd Misoprostol placed
Obstructive Sleep ApneaMore common with obese patients
Associated with
• Fetal growth restriction
• Preeclampsia
• Stillbirth
Only recently studied in pregnant woman
• Tx appears to improve apnea
• No in pt outcomes
Louis, J.M. et. al., (2012) Am J Obstet Gynec
Requires Anesthesia consult
• Hypoxemia
• Hypercapnia
• Sudden Death
Risk of Prematurity/Stillbirth
PTL results are mixed PTB – underlying conditions
• Fetal growth restriction• HTN• PreE• GDM• DM
Risk of Stillbirth
• with GA
• with class of obesity
Yao, R., (2014) Am J Obstet Gynecol
Flenady, V., et. al., (2011) Lancet
Ehrenberg H.M., (2009) Obstetrics & Gynecology
Obesity and Cesarean Birth
Since 1996 the U.S. C/S rate has > 60%
Currently the U. S. C/S rate is 32.8%
More likely to have significant M&M:
• Post-op Infection
• Clotting disorder
• Hemorrhage
• Prolonged hospitalization
1/3 of maternal death are associated with obesity complications
Carlson et. al., (2014) Journal of Midwifery & women’s Health
Obesity and Cesarean Birth
Nulliparous obese women
• Highest risk for C/S
• More likely to be induced
• More likely to have slow labor progress
• Less likely to have accelerated cervical change in active phase
• More like to have “failed induction”
Carlson et. al., (2014) Journal of Midwifery & women’s Health
Equipment and Supplies for Safe Care
Each facility needs to determine it’s ability to provide care for class III obesity women giving birth
Kriebs (2014) Am J. JPNN
Equipment and Supplies for Safe Care
Anesthesia Concerns
IV Access
Epidural
• Positioning
• Identification of landmarks
• Inconsistent spread of of anesthetic
• Dislocation of the catheter
• Increased risk for dural puncture
General Anesthesia
• Decreased chest wall compliance
• Increased abdominal pressure
• Rapid desaturation
• Increased risk of aspiration
Mace, H.S., et al., (2011) Anaesth Intensive care
Anesthesia Concerns
Epidural Challenges
Longer needles
Sized BP Cuff
Pulse Oximetry
Continuous FHR tracing
Anesthesia Concerns
Airway Challenges
C/S and Perioperative Concerns
• Retracts and holds adipose tissue (pannus)
https://www.youtube.com/watch?v=SyqZfxNdfA0
C/S and Perioperative Concerns
Emergency Delivery
Prolonged incision to delivery interval (up to 3 hours)
PPH with blood loss > 1000 mL
• Macrosomia
• Volume : distribution ( bioavailability of uterotonic agents)
Post op infection, would infection, dehiscence, episiotomy, endometritis – higher dose/prolonged antibiotics
• Poor vascularity of the sub Q adipose tissue seromashematomas
Post-op complication
• Pulmonary complications, VTE
The Problem of the Pannus
https://www.youtube.com/watch?v=07NSyJvEjYQ
Safety concerns for nurses
Employees injuries are more common with obese patients
Careful attention hydrotherapy: showering, tubs
Utilize walker, shower chair, bariatric wheelchair
Call for assistance – lift team
Don’t hold legs – can be injured
Hover matt
Carlson et. al., (2014)
Journal of Midwifery & women’s Health
Obesity and Breastfeeding
Failure to initiate lactation
Lactation duration
Mechanism:
• Alteration in Hypothalamic Pituitary-Gonadal axis (HPGA)
• Alteration in fat metabolism
• prolactin response to sucking
SUPC with unsupervised skin to skin
Implications for future
What is the right time to induce
Should AROM be delayed
What is the optimal timing and dosage of oxytocin
Department guideline
Bariatric Designation
Improving anesthesia and surgical techniques
Strategies specific for breastfeeding
Postpartum follow-up “Boot Camp for obese Mom’s”
Summary
Obesity is associated with significant maternal and neonatal morbidity and mortality
Optimal timing of labor induction is yet to be determined
Unit P&P for Obese women promotes respectful, safe, high quality, reliable care
Obese women warrant heightened surveillance during childbirth
Nurses need to provide specialized care for obese women that is, and safe for the patient, the newborn, and themselves
ReferencesACOG Committee Opinion No. 600. American College of obstetricians and Gynecologists.
Ethical issues in the care of the obese woman. Obstet Gynecol 2014;123:1388–93.
AWHONN’s Guidelines for Professional Registered Nurse Staffing. Association of Women’s
Health, Obstetric and Neonatal Nurses, Washington DC, 2010.
Bariatric times, on line journal_July 2010, access November, 2014
Centers for Disease Control and Prevention. Adult obesity facts.
http://www.cdc.gov/obesity/data/adult.html. Accessed October 2014.
Carlson, N S, & Lowe, N K. (2014). Intrapartum management associated with obesity in
nulliparous women. Journal of midwifery & women's health, 59(1), 43-53.
Hilliard AM, Chauhan SP, Zhao Y, Rankins NC. Effect of obesity on length of labor in
nulliparous women. Am J Perinatol. 2012;29:127–132.
Gauthier T, Mazeau S, Dalmay F, et al. Obesity and cervical ripening failure risk. J Matern
Fetal Neonatal Med. 2012;25(3):304-307.
Jensen MD, Ryan DH, Apovian CM, Loria CM, Ard JD, Millen BE, et al. 2013 AHA/ACC/TOS
guideline for the management of overweight and obesity in adults: a report of the
American College of Cardiology/American Heart Association Task Force on
Practice Guidelines and The Obesity Society. J Am Coll Cardiol 2013; DOI:
10.1016/jjacc.2013.11.004.
References Kominiarek MA, Zhang J, VanVeldhuisen P, et al. Contemporary labor patterns: the impact
of maternal body mass index. Am J Obstet Gynecol. 2011;205(3):244.e1-244.e8.
Mace HS, Paech MJ, McDonnell NJ. Obesity and obstetric anaesthesia. Anaesth Intensive Care. 2011;39(4):559–570.
Stothard KJ, Tennant PWG, Bell R, Rankin J. Maternal overweight and obesity and the risk of congenital anomalies. Asystematic review and meta-analysis. JAMA. 2009;301(6):636–650.
Vahratian A, Zhang J, Troendle JF, Savitz DA, Siega-Riz AM.Maternal prepregnancy overweight and obesity and the pattern of labor progression in term nulliparous women. Obstet Gynecol. 2004;104 (5,Part1):943.
Yao, R, Ananth, C V, Park, B Y, et al. (2014). Obesity and the risk of stillbirth: a population-based cohort study. American journal of obstetrics and gynecology,
Nurses are a valuable source
of information and support
for women and their families
Thank You
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