Intrapartum Management of the Patient With Obesity

What Is Obesity and How Does It Complicate Pregnancy?

Being overweight is a body mass index (BMI) between 25 and 29.9. A person with a BMI of 30 or more is obese. Within the broad category of obesity, three levels reflect the rising health risks associated with increasing BMI:

• Obesity Category I- BMI between 30 and 34.9.

• Obesity Category II- BMI between 35 and 39.9.

• Obesity Category III- BMI 40 or higher.

BMI can be easily calculated using a BMI calculator.

Obesity during pregnancy puts pregnant women at risk for a number of serious health issues, including-

• Preeclampsia - Preeclampsia is a severe form of gestational hypertension usually occurring in the second half of pregnancy or shortly after the delivery of the baby. This condition can lead to the kidneys and liver failing in women. Seizures, heart attacks, and strokes may occur in rare cases. Other complications include problems with the placenta and fetal growth.

• Obstructive Sleep Apnea - Sleep apnea is a condition in which a person briefly stops breathing while sleeping. Fatigue and an increased risk of preeclampsia, hypertension, and heart and lung issues during pregnancy can all be brought on by sleep apnea.

• Gestational Hypertension - Gestational hypertension is high blood pressure that begins in the second half of pregnancy. It has the potential to cause serious maternal complications.

• Gestational Diabetes - High glucose (blood sugar) levels during pregnancy increase the chances of having a very large baby. This also increases the likelihood of cesarean birth. Women who have had gestational diabetes are more likely to develop diabetes later in life, as well as their children.

What Complications Can Occur in Pregnant Women With Obesity?

Obesity increases the risk of the following pregnancy complications-

• Preterm Birth - Obesity-related issues, such as preeclampsia, may result in a medically indicated preterm birth. This means that the baby was born prematurely for medical reasons. Compared to newborns delivered after 39 weeks of pregnancy, preterm babies are less developed. Premature infants are, therefore, more likely to experience both immediate and long-term health problems.

• Stillbirth - The risk of stillbirth increases with the woman's BMI.

• Birth Defects - Babies born to obese mothers are more likely to have birth defects such as heart defects and neural tube defects (NTDs).

• Macrosomia - The size of the fetus is larger than normal in this condition. This can increase the risk of birth injury. For example, the fetus's shoulder may become stuck after the head is delivered. Macrosomia also increases the likelihood of having a cesarean birth. Infants born with excessive body fat have a higher risk of becoming obese later in life.

• Diagnostic Test Complications - Too much body fat can make it difficult to see certain fetal anatomy problems on an ultrasound exam. It could be more challenging to monitor the fetus' heart rate during labor if the expectant mother is obese.

What Is the Effect of Obesity on Labor and Delivery?

Women who are overweight or obese experience longer labor than women of normal weight. It could be more challenging to monitor the fetus during labor. For these reasons, being obese during pregnancy increases the chance of needing a cesarean delivery. If a cesarean birth is required, the risks of infection, bleeding, and other complications are higher for an obese woman than for a normal-weight woman.

What Measures Are Taken for Intrapartum Management of the Patient With Obesity?

Women with obesity, particularly those with super-obesity, require a multidisciplinary approach to intrapartum care.

The following steps are being taken-

• Basic Management -

  • Anesthetic Considerations - Before hospitalization, obstetric anesthesia specialists should meet with the patient to evaluate comorbidities, assess pulmonary and cardiovascular status, and obtain an airway exam. Because epidural anesthesia placement is more difficult in obese patients, it takes longer to place and is more likely to require replacement; early labor epidural placement should be considered.

Obesity and opioid pain medications increase the risk of hypoventilation, and collaboration with anesthetic providers is required for safe management. In addition, IV (intravenous) access is necessary for labor and delivery. However, it must be approached with the goal of obtaining access while causing the patient the least amount of discomfort.

Depending on the patient's airway examination results, the anesthesia team may decide to place the patient on a ramp in case endotracheal intubation is required. In the obese population, reliable non-invasive blood pressure monitoring can be complex.

• Facility Logistics - Physical space, adapting equipment created for patients with obesity, staff skilled in bariatric patient transfer, and bigger doorways and elevators with higher maximum weight allowances are all crucial for the bariatric patient. Additional factors include bariatric wheelchairs and commodes, huge surgical safety belts, portable or ceiling-mounted lifting equipment, sequential compression devices, and wheelchairs for overweight people.

• Delivery and Labor Considerations - An independent risk factor for cesarean delivery is obesity. Obese women are more likely to have an abnormal labor curve, significantly lengthening the entire labor time and the progression through latent labor. Furthermore, obese women are more likely to experience a prolonged second stage of labor than those nulliparous women who attain complete dilatation.

• Fetal Assessment - Leopold maneuvers and a vaginal exam may not be sufficient to assess fetal presentation in the context of obesity; therefore, ultrasound assessment for fetal presentation may be required. Sometimes it is impossible to measure the fetal heart rate with cardiotocography because of the patient's body habitus. An ultrasound may be needed to determine where a fetal monitor should be placed. It might be essential to perform an amniotomy and install internal monitors, such as a fetal scalp electrode.

• Surgical Management -

  • Surgical Considerations - Super obesity, in particular, has been linked to higher rates of problems following cesarean delivery. Increased operating duration and anticipated blood loss are related to higher BMI. Extremely likely intraoperative injuries in super-obese women include wide ligament hematomas, perioperative transfusion, reoperation, hysterectomy, bladder, bowel, or ureteral injury.

  • Antibiotic Prophylaxis - All women having cesarean deliveries are advised to take broad-spectrum antibiotics. Higher doses are typically advised for obese women. Due to a larger surface area, preparing abdominal skin with two or more chlorhexidine-alcohol swabs is advised. Vaginal preparation should be considered, particularly in women with ruptured membranes, as obese women are more likely to develop postpartum endometritis.

  • Surgical Positioning and Incision - Although the ideal surgical setting for obese, and particularly super-obese, women undergoing cesarean delivery is yet unknown, extra emphasis is paid to pannus retraction and maternal pressure point reduction. The type of skin incision is chosen based on the distribution of the mother's body habits, accessibility to the lower uterine segment, and preferences of the mother and the doctor.

  • Surgical Closure - According to the existing research, women with at least 2 cm of adipose tissue should have the subcutaneous tissue closed; this procedure has been found to dramatically lower the rate of postoperative wound disruption.

• Postpartum Care -

  • It covers safe transfers, repositioning, access to the abdomen and the perineum, bathing, showering, and recovering from falls. The postpartum period requirements for the patient with super obesity may include a bariatric bed as well as a bariatric lift to improve safety.

  • Depending on the specific patient and delivery factors, initial postoperative recovery may require an ICU (intensive care unit) setting.

  • For patients with limited mobility, physical and occupational therapy might be beneficial. It can help patients regain the ability to walk. Skin disintegration, heart deconditioning, deep vein thrombosis, muscle atrophy, urine stasis, constipation, pain management issues, and depression are typical immobility-related consequences. Atelectasis and pneumonia are pulmonary problems that are further exacerbated by immobility.

  • Pregnancy increases the chance of developing or maintaining obesity, and events connected to obesity during pregnancy are linked to long-term metabolic dysfunction.

  • The patient needs proper care and continuous monitoring of the vitals until discharge.

Conclusion:

Pregnancy in an obese patient is more complicated than in a gravid patient without an elevated BMI, with increased maternal and fetal risk based on the level of obesity. In addition, these women's antepartum, intrapartum, and postpartum needs necessitate more time, resources, and experience from healthcare providers.