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

Valerie.Huwe@ucsf.edu