new obesity in pregnancy guideline · 2020. 8. 17. · obesity in pregnancy guideline guideline...

Obesity in Pregnancy Guideline Guideline

Reference Number WAC023

Status Approved

Version 9

Implementation Date February 2009

Current/Last Review Dates October 2010, October 2011, September 2012, November 2013, May 2014, September 2015, March 2019, July 2019

Next Formal Review July 2022

Sponsor Clinical Director for Obstetrics

Sponsor Signature

Author Obstetric Consultant

Where available Intranet

Target audience Midwifery, Obstetric and anaesthetic staff

Ratification Record

Approval Record

Committee Name Chairperson Date

Labour Ward Forum Lead Consultant August 2019

Consultation Date

All Obstetric consultants August 2019

All Anaesthetist consultants August 2019

Head of Midwifery August 2019

Professional Midwifery Advocates August 2019

Regulators Requirements

NICE guidelines 2019 NG121

CNST Maternity Clinical risk Management Standard

Clinical Care 3.10

RCOG 2010

Document Control / History

Version No Reason for change

1 New policy

2 Revision of guidelines and to ensure compliance with new Trust format for policies and procedures

3 New joint guideline from CMACE/RCOG - update existing guideline

4 To ensure compliance with 2012 CNST standards.

5 Amendment to section 9

6 Further amendments to section 9

7 Amendment to layout

8 Triennial review, updates to scan frequency

9 Incorporated changes from new NICE Guideline (sections 8, 9 and 12)

Title: Obesity in Pregnancy Guideline Date: March 2019 Ref: WAC023 (v8) Status: Approved

_____________________________________________________________________________________________________ Dartford and Gravesham NHS Trust of 23

Contents Section Page Document Summary 3 1. Introduction 4 2. Purpose 4 3. Definitions 4 4. Duties (Roles and Responsibilities) 4 5. Calculation and recording of the body mass index (BMI) for all women 5

6. Pre-pregnancy care 6 7. Obesity and exercise 8 8. Antenatal care pathways 8

8.1 Booking 8 8.2 Blood pressure measurements 8 8.3 Risk factors 8 8.4 Glucose tolerance tests 9 8.5 Additional Ultrasound scans 9 8.6 Thromboprophylaxis 9 8.7 Anaesthetist review 10 8.8 Birth plan 10

9. Place of Birth 10 10. Induction of labour 11 11 Vaginal birth after caesarean (VBAC) 11 12. Postnatal Care all Women with BMI >30 12 13. Facilities and Equipment 12 14. Assessment of availability of suitable equipment 13 15. Training and Implementation 13 16. Monitoring Compliance with this Procedural Document 13 17. Associated Documents/Further Reading 13 18. References 13 Appendices 1 Care pathway for obesity management in pregnancy 16 2 Care planning for women with BMI > 30 18 3 Anaesthetic care plan for obese women (BMI > 40) 20

Document Summary Maternal obesity has become one of the most commonly occurring risk factors in obstetric practice.

This guideline exists to support health professionals in providing appropriate care for pregnant women who have a BMI (greater than) 30.

Author Miss Singh, Consultant Obstetrician Revised by Ms Sara Thomson, ST4 Registrar in Obstetrics, Mr K Sampat, Lead Consultant for Obstetric Risk and Governance



1. Introduction There is substantial evidence that obesity in pregnancy contributes to increased morbidity and mortality for both mother and baby. The prevalence of obesity in the general population is increasing and this is reflected in the pregnant population. This has risen from 9 -10% in the early 1990s to 16 -19% in the 2000s. MBRRACE-UK (2018) reported that 30% of women who died were obese and 22% were overweight.

CEMACH 2003–5 recommended that women with a BMI 30 kg/m² or more should be seen for pre-

pregnancy counselling. The CMACE/RCOG Joint Guidelines ‘Management of Obesity in Pregnancy’ has been used in the development of this guideline.

2. Purpose The purpose of this guideline is to ensure that maternity staff are aware of the systems in place to manage the risks associated with obesity in an effort to improve outcomes for mother and baby. It is also to outline the service provision for obese women in pregnancy and improve the outcomes for these women and their babies at Darent Valley Hospital.

3. Definitions Body Mass Index (BMI) Body Mass Index (BMI) is a calculation of height to weight ratio that provides a reliable indicator of body fat for most people and is used to screen for weight categories that may lead to health problems Obesity is a medical condition in which excess body fat has accumulated to the extent that it may have an adverse effect on health. Thromboprophylaxis: is the practice of giving small doses of anticoagulant drugs to individuals with an increased risk of venous thrombosis. 4. Duties (Roles and Responsibilities) Directorate Midwifery Managers It is the responsibility of the Directorate midwifery managers to ensure that midwives are aware of the guideline and its application in practice. Midwives and Obstetricians It is the responsibility of the midwives and obstetricians to ensure that they are aware of this and national guidelines in order to facilitate the correct care pathway for women. The midwife is responsible for calculating and recording BMI, at booking, in the hand held records / electronic patients’ records and for referring any woman with a BMI > 35 to consultant led care. The obstetrician is responsible for the clinical management of women with a high BMI and referral to anaesthetist. Anaesthetists It is the responsibly of the anaesthetists to ensure that high risk women who fulfil criteria for anaesthetic referral are reviewed, a risk assessment is carried out and the findings are documented in the patients’ antenatal records.

5. The Calculation and Recording of the BMI for all Women All women should have their weight and height accurately measured at the initial booking interview with their shoes off, standing erect using a wall-mounted metre-stick and their BMI calculated. . Measurements should be recorded in their hand held notes / electronic patients’ records (E3). Estimations are not acceptable. If a woman is transferring care from another hospital after 20 weeks of pregnancy and has previously had her BMI accurately calculated then this documented measurement should be used and the appropriate care pathway determined. BMI is defined as the individuals body weight in kgs divided by their height in metres squared. The BMI is calculated based on the formula: BMI = Patients weight in kgs Patients Height in metres (squared ²) Table 1. Classification of adults according to BMI

Classification BMI

Underweight <18.50

Normal Range 18.50-24.99

Overweight >25.00

Preobese 25.00-29.99

Obese class I 30.00-34.99

Obese class II 35.00-39.99

Obese class III >40 Table 2 - BMI chart for Adults



6. Pre-pregnancy Care Women of childbearing age with a BMI 30 kg/m2 or greater should receive information and advice about the risks of obesity during pregnancy and childbirth and be supported to lose weight before conception and between pregnancies in line with NICE Clinical guideline (CG) 189. Women should be informed that weight loss between pregnancies reduces the risk of stillbirth, hypertensive complications and fetal macrosomia. Weight loss increases the chances of successful vaginal birth after caesarean (VBAC) section. Woman should be informed that that maternal and fetal risk increases as BMI rises.

Table 2 - Obstetric Complications in Obese Pregnant Women

Early pregnancy Miscarriage Congenital anomalies e.g. neural tube defects Late pregnancy Preterm labour Hypertension/ pre-eclampsia Gestational diabetes Thrombo-embolism Labour & Delivery Difficulty in fetal surveillance Prolonged labour/ dysfunctional labour Increased rate of instrumental deliveries Increased perineal trauma Increased incidence of shoulder dystocia Increased incidence of genital and urinary tract infections Instrumental deliveries Caesarean sections Primary postpartum haemorrhage Higher risk of anaesthetic complications Postpartum Increased risk of perineal / caesarean wound breakdown and infection Postpartum endometritis Secondary PPH Postpartum thrombophlebitis / thromboembolism Reduced breastfeeding Fetus and neonate Macrosomia Intrauterine Growth Restriction Intrauterine death Early neonatal death Hypoglycaemia Childhood adiposity Meconium aspiration Birth trauma Neural tube defects Cardiovascular anomalies Ano-rectal atresia Hydrocephaly Limb reduction anomalies Septal anomalies

6.1 Vitamin supplements It is recommended that obese women should take high dose (5mg) folic acid for at least one month before conception and continue throughout the first trimester as obese women are at increased risk of neural tube defects.



Interpregnancy weight reduction among women with obesity has been shown to significantly reduce the risk of developing gestational diabetes (GDM). Studies found that a weight loss of at least 4.5 kg before the second pregnancy reduced the risk of developing GDM by up to 40%. Although it has been suggested that some weight loss regimens during the first trimester may increase the risk of fetal neural tube defects (NTD), weight loss prior to pregnancy does not appear to carry this risk. There is a lack of consensus on optimal gestational weight gain. Until further evidence is available, a focus on a healthy diet may be more applicable than prescribed weight gain targets

7. Obesity and exercise Unless there are medical or obstetric contradictions obese women should be encouraged to maintain regular exercise during and after pregnancy. Maintaining exercise during pregnancy may have many benefits including short terms benefits to the baby and long term benefits for the mother and further pregnancies. Physical exercise during pregnancy is associated with a decreased risk of pre-eclampsia and gestational diabetes mellitus. 8. Antenatal Care Pathways 8.1 Booking BMI > 18.5 and 29.9 can be booked for midwifery led care, homebirths and water births. BMI > 30:

• Midwives to complete the “Obesity management in pregnancy” Proforma (Adagio see appendix 2) and file it in hand held notes.

• Provide the leaflet: “Obesity in Pregnancy and Pregnancy Plus Information for Expectant Women”. They should be given the opportunity to discuss this leaflet and referral to the Pregnancy Plus scheme.

BMI of 30 - 34.9 can be booked for midwifery led care as long as there are no other risk factors and once they have been reviewed by an obstetrician at 16 weeks. BMI > 35 should be advised to book for and be referred for consultant led care. BMI > 40 All women with a booking BMI >40 should be referred for Consultant Care as early as possible. They should be advised to deliver on Delivery Suite (obstetric led unit). A minimum waiting period of 12 –18 months after bariatric surgery is recommended before attempting pregnancy to allow stabilisation of body weight and to allow the correct identification and treatment of any possible nutritional deficiencies that may not be evident during the first months. 8.2 Blood pressure measurements The appropriate size blood pressure cuff must be used and the size of the cuff used documented in the notes. It is recommended that the mid-arm circumference (MAC) should be measured if BMI > 29.9 at their first antenatal visit. If the MAC is > 33cms, a large cuff should be used for BP measurements. 8.3 Risk factors No additional risk factors Women with a booking BMI >35 with no additional risk factor can have community monitoring for preeclampsia at a minimum of:

3 weekly intervals between 24 and 32 weeks gestation,

2 weekly intervals from 32 weeks to delivery. One additional risk factor Women with a booking BMI >35 who also have at least one additional risk factor for preeclampsia should have referral early in pregnancy for specialist input to care. Additional risk factors include:

• first pregnancy, • previous pre-eclampsia, • >10 years since last baby, • >40 years, family history of pre-eclampsia, • booking diastolic BP >80mmHg, • booking proteinuria >1+ on more than one occasion or >0.3g/24 hours, • multiple pregnancy, • and certain underlying medical conditions such as antiphospholipid antibodies or pre-existing

hypertension, renal disease or diabetes. More than one additional risk factor The NICE Clinical Guideline on Hypertensive disorders during pregnancy states that women with more than one moderate risk factor may benefit from taking 75mg to 150 mg aspirin daily from 12 weeks’ gestation until birth of the baby. 8.4 Glucose tolerance tests BMI 30 – 35. GTT at 28 weeks is recommended if there is a first degree relative with diabetes / their family origin is South Asian, Black Caribbean or Middle Eastern. BMI > 35 GTT at 28 weeks and appropriate referral if gestational diabetes diagnosed. 8.5 Additional Ultrasound scans BMI > 35 Growth scans at 30 and 36 weeks gestation. BMI > 40 Growth scans at 30 and 36 weeks gestation 8.6 Thromboprophylaxis Women with a booking BMI > 30 should be risk assessed at booking and every visit for risk of thromboembolism. The RCOG Clinical Green Top Guideline No. 37 advises that: A woman with a BMI >30 who also has two or more additional risk factors for thromboembolism should be considered for prophylactic low molecular weight heparin (LMWH) antenatally. Referral to an Obstetric Consultant is needed. This should begin as early in pregnancy as practical. All women receiving LMWH antenatally should usually continue prophylactic doses of LMWH until six weeks postpartum, but a postnatal risk assessment should be made.



The RCOG Clinical Green Top Guideline No. 37 gives the following weight-specific dosage advice: Weight (kg) Dose 91-130 60 mg Enoxaparin; 7500 units Dalteparin; 7000 units Tinzaparin daily 131-170 80 mg Enoxaparin; 10000 units Dalteparin; 9000 units Tinzaparin daily >170 0.6 mg/kg/day Enoxaparin; 75 units/kg/day Dalteparin; 75 units/kg/day Tinzaparin _____________________________________________________________________________________________________ All women with a BMI >40 should be advised to have postnatal thromboprophylaxis for at least 10 days regardless of their mode of delivery and TED stockings should be worn irrespective of mode of delivery. 8.7 Anaesthetist review BMI > 40 must have an antenatal anaesthetic review with obstetric anaesthetist at 32 – 34 weeks informing the woman with BMI>40 the importance of this appointment because of the increased risk of anaesthetic complications. A clinical assessment form (Appendix 3) detailing discussion on anaesthetic management plan for labour and delivery will be completed and a copy placed in her case notes (the orange notes). BMI 35- 40 should be reweighed at 30 – 32 weeks, if weight gain > 9 kg, refer to anaesthetist. BMI > 35 – 39.9 and pre-existing co-morbidities must have an antenatal anaesthetic review with obstetric anaesthetist at 32 – 34 weeks. Women with BMI 30 kg/m2 or greater are at increased risk of mental health problems and should therefore be screened for these in pregnancy. There is insufficient evidence to recommend a specific lifestyle intervention to prevent depression and anxiety in obese pregnant women 8.8 Birth plan For women with a BMI over 30 kg/m2 at the booking appointment, carry out a risk assessment in the third trimester. When developing the birth plan with the woman, take into account:

the woman's preference

the woman's mobility

comorbidities

the woman's current or most recent weight

9. Place of Birth BMI 30 – 35 Women can deliver on the birthing centre, if there are no additional risk factors Consider ultrasound scanning at the start of established labour if the baby's presentation is uncertain, for women with a BMI over 30 kg/m2 at booking. Base intrapartum fetal monitoring on the woman's preference and other obstetric indications (including no antenatal care), for women with a BMI over 30 kg/m2 at booking and no medical complications.

For women with a BMI over 30 kg/m2 at booking and reduced mobility in the third trimester, consider advising the lateral position in the second stage of labour. For women with a BMI over 30 kg/m2 at booking and adequate mobility, provide care in the second stage of labour as per standard intrapartum recommendations. BMI 35 - 40 Multiparous women can be delivered on the birthing centre providing there are no additional risk factors. Nulliparous women should have an individual risk assessment as part of their birth planning discussion, regarding place of birth. Active management of the third stage of labour should be recommended because of the increased risk of postpartum haemorrhage. Strongly consider ultrasound scanning at the start of established labour if the baby's presentation is uncertain. BMI > 40

• Women with a BMI >40 should be advised to deliver in the Delivery Suite (obstetric led). • Correct size blood pressure cuff must be available and used. • An assessment for the risk of thromboembolism should be performed on admission. • The portable scanner should be used to check / confirm presentation on admission. • In view of the importance of obtaining an adequate fetal heart trace, consideration should be

given to using a fetal scalp electrode early in labour. • The anaesthetic middle grade should be informed of the woman’s admission. • Adequate analgesia should be provided. If an epidural is the preferred choice of analgesia it

should be sited early. The on call consultant anaesthetist should be informed of the woman’s admission if BMI > 50.

• Intravenous access with a large gauge cannula should be established in labour due to the increased risk of complications.

• A copy of the antenatal anaesthetic risk assessment should be available in the notes and reviewed by the duty anaesthetist on call when the woman is admitted in labour.

• Water and isotonic sports drinks only should be given in labour. • Any additional equipment required should be available and used. • Pressure areas should be checked two-hourly and skin integrity maintained. This

should be documented in the notes. • Active management of the third stage of labour should be recommended because of the

increased risk of postpartum haemorrhage.

10. Induction of labour Elective induction of labour at term in obese women may reduce the chance of caesarean birth without increasing the risk of adverse outcomes; the option of induction should be discussed with each woman on an individual basis. Where macrosomia is suspected, induction of labour may be considered. Parents should have a discussion about the options of induction of labour and expectant management.

11. Vaginal birth after caesarean (VBAC) Women with a booking BMI >30 should have an individualised decision for VBAC following informed discussion and consideration of all relevant clinical factors. Obesity is not a contraindication for attempting a VBAC. Obesity is however a risk factor for unsuccessful VBAC, and morbid obesity carries a greater risk for uterine rupture during trial of labour



and neonatal injury. Continuous fetal monitoring is recommended. Emergency caesarean section in women with obesity is associated with an increased risk of serious maternal morbidity because anaesthetic and operative difficulties are more prevalent in these women compared to women with a healthy BMI, and this should also be taken into account when discussing the risks and benefits of VBAC.

12. Postnatal Care all Women with BMI >30

• Early mobilisation should be encouraged. • Breast feeding should be encouraged. Appropriate support should be given to women

postnatally regarding the benefits, initiation and maintenance of breastfeeding. • Any wounds should be observed for signs of dehiscence and infection. The woman should be

advised to keep wound dry. • Women should be given advice on the signs of deep vein thrombosis (DVT) and pulmonary

embolism (PE). • The woman’s weight should be discussed postnatally. The benefits of a healthy diet and

exercise should be discussed and the benefits to a future pregnancy of her losing her pregnancy weight gain discussed.

• Fragmin. All women with a BMI greater than 40 at booking, should be recommended to have at least ten days of Fragmin after delivery. This should be extended to six weeks in the presence of other risk factors for venous thrombosis.

13. Facilities and Equipment All equipment which can be used for obese pregnant women has a safe working load in kilograms. It is important that all pregnant women with a booking BMI > 40 are reweighed during the third trimester of pregnancy so appropriate equipment can be organised if necessary. Midwives should refer to the Trust’s Operational Guideline: MAH003 “Care of the Bariatric Patient” to ensure all requirements are met. A manual handling risk assessment should be completed in the 3rd trimester and on admission for all women with a booking BMI > 40 or weight > 152kg / 24 stone by the midwife and if necessary the moving and handling department and tissue viability nurse. Individual documented risk assessment must be carried out to determine manual handling requirements for childbirth and consider tissue viability issues. A list of all available trust manual handling equipment for bariatric patients including the weight limit and location of each item is contained within “Care of the Bariatric Patient” Ref MAH003 policy.

The moving and handling department can be contacted on Ext 8248 or e-mail: [email protected]



14. Equipment Assessment The Maternity Department has a central list of all available Trust manual handling equipment for bariatric patients including the weight limits and location of each item. Within the maternity unit the following equipment is available:

• Large blood pressure cuffs with bladder dimensions of 12 x 40 cm (All Maternity Wards / ANC must ensure they have these large blood pressure cuffs).

• Extra-long spinal needles (18-20cm) for regional analgesia • Operating table that supports women of a weight of 180kg (serviced annually by the

company)

Delivery Beds that support women up to weight of 180kg. (Please note the double

bed in Serenity is a bariatric bed) • Ward beds that support women up to weight of 230kg. • Step on scales that weigh women up to 200kg (31.5 stone). • For equipment located outside Maternity Department, when women with BMI > 40

are due to deliver or are booked to attend for delivery, the Delivery Suite Coordinator must ensure the availability of: Step on / wheelchair scales which weigh up to a maximum of 318kg (50 stone) {located in the moving and handling training room / obtained from the Trust Bariatric Nurse if required}. Bariatric beds for antenatal/postnatal ward are also available from the same source / venue.

15. Training and Implementation

• All clinical staff involved in the care of obese women should have biannual manual handling training and training on the use of specialist equipment for pregnant obese women.

• All health professionals involved should receive education about maternal nutrition and its impact on maternal, fetal and child health.

15.1 Implementation and Dissemination Many of the requirements documented within this guideline are in already place, but changes highlighted to this guidance will be disseminated via:

• Monthly newsletter • Labour Ward forum • All medical and midwifery staff on induction

This guideline will be accessible electronically on the Trust intranet. 16. Monitoring Compliance with this Procedural Document The Midwifery Managers will monitor compliance with the record keeping standards of this guideline and also to ensure that staff know where Bariatric equipment can be obtained. The minutes of these meetings will provide an accurate record of the discussions and action points identified. More detailed monitoring is described in the following table:



Objective to be monitored/audited

Measure/Tool Frequency Lead Reporting arrangements

Actions arising including identifying leads to take actions forward in agreed timescales

Changes to practice and lessons learned.

Audit to ensure that all women have their BMI calculated and recorded

Maternity Services Hand

held using record keeping audit tool

notes Trust

Annually

SOM’s

SOM meetings Audit meetings

Any deficiencies identified including • Individual feedback to

relevant practitioner documentation etc

• Training needs identified

As identified in action plan from audit results

Audit of care pathways for women with BMI > 30:

Thrombo- prophylaxis-

assessment and implementation

Audit of care pathways for women with BMI > 35: Have place of

delivery discussed and documented

Audit of care pathways for women with BMI > 40:

Have an antenatal

anaesthetic referral

Hand notes ensure proforma completed

held to

17. Associated Documents/Further Reading

• RCOG (2009) Thromboprophylaxis during Pregnancy, Labour and the Puerperium • WAC065- Caesarean Section Guideline • WAC061- Clinical Risk Assessment Guideline • CMACE/RCOG (2010) Management of Obesity in pregnancy • NICE (2010) Hypertension in Pregnancy • NICE (2008)- Diabetes in pregnancy • MAH003- Care of the Bariatric Patient • NICE (2019) Intrapartum care for women with existing medical conditions or obstetric

complications and their babies

18. References Association of Anaesthetists of Great Britain and Ireland, and the Obstetric Anaesthetists’ Association. (2005). OAA/AAGBI Guidelines For Obstetric Anaesthetic Services (Revised edition). London: AAGBI/OAA. Available at: www.aagbi.org.uk and www.oaa-anaes.ac.uk Confidential Enquiries into Maternal Deaths in the United Kingdom. (2011). Saving Mothers’ Lives: Reviewing Maternal Deaths To Make Motherhood Safer: 2006-2008. London: Wiley-Blackwell.

http://www.aagbi.org.uk/

http://www.aagbi.org.uk/

http://www.oaa-anaes.ac.uk/






Available at: http://onlinelibrary.wiley.com Centre for Maternal and Child Enquires, Royal College of Obstetricians and Gynaecologists (2010). Management Of Women With Obesity In Pregnancy. London: CMACE/RCOG. Available at: http:///www.rcog.org.uk Centre for Maternal and Child Enquiries (2010). Maternal Obesity In The UK: Findings From A National Project. London: CMACE. Available at: www.oaa-anaes.ac.uk Confidential Enquiries into Maternal Deaths in the United Kingdom. (2011). Saving Mothers’ Lives: Reviewing Maternal Deaths To Make Motherhood Safer: 2006-2008. London: Wiley-Blackwell. Available at http://onlinelibrary.wiley.com Department of Health. (2007). Maternity Matters: Choice, Access And Continuity Of Care In A Safe Service. London: COI. Available at: www.dh.gov.uk National Institute for Health and Clinical Excellence (2019). NG121 Intrapartum care for women with existing medical conditions or obstetric complications and their babies. Available at www.nice.org.uk. Nursing and Midwifery Council (2015) The Code: Standards Of Conduct, Performance And Ethics For Nurses And Midwives. London: NMC. Available at: www.nmc-uk.org Royal College of Obstetricians and Gynaecologists, Royal College of Anaesthetists, Royal College of Midwives, Royal College of Paediatrics and Child Health. (2008). Standards For Maternity Care: Report Of A Working Party. London: RCOG Press. Available at: www.rcog.org.uk

Royal College of Obstetricians and Gynaecologists. Care of Women with Obesity in Pregnancy. Green-top Guideline No. 72. BJOG 2018;

http://onlinelibrary.wiley.com/doi/10.1111/bjo.2011.118.issue-s1/issuetoc









http://www.dh.gov.uk/

http://www.dh.gov.uk/

http://www.nice.org.uk/

http://www.nmc-uk.org/




http://www.rcog.org.uk/

http://www.rcog.org.uk/



Appendix 1. Care pathway for management of pregnancy with obesity. Please print and put in patients notes

BOOKING BMI 30 – 34.9

BOOKING BMI 35 – 39.9

BOOKING BMI > 40

Consultant led/ Midwifery led

Consultant led

Consultant led

BOOKING APPOINTMENT

☐ Open discussion on the risks of

obesity to mother and baby should take place and written information also given. ☐ Documentation of discussion


obesity to mother and baby should take place and written information also given. ☐ Documentation of discussion


obesity to mother and baby should take place and written information also given. ☐Documentation of discussion

☐To take 5mg folic acid supplementation

for first 12 weeks of pregnancy as obese women are at increased risk of neural tube defects

☐ To take 5mg folic acid

supplementation for first 12 weeks of pregnancy as obese women are at increased risk of neural tube defects

☐ To take 5mg folic acid

supplementation for first 12 weeks of pregnancy as obese women are at increased risk of neural tube defects

☐ Information about exercise, i.e. 30

minutes of exercise 5 times a week e.g. walking, swimming, aquanatal ☐ Referral to pregnancy plus

☐ Information about exercise, i.e. 30

minutes of exercise 5 times a week e.g. walking, swimming, aquanatal ☐ Referral to pregnancy plus

☐ Information about exercise, i.e.

30 minutes of exercise 5 times a week e.g. walking, swimming, aquanatal ☐ Referral to pregnancy plus

☐ Risk assessment at booking for thromboembolism

☐ Risk assessment at booking for

thromboembolism ☐ Risk assessment at booking for

thromboembolism

AT 28 WEEKS

☐ Glucose tolerance test GTT is recommended if there is family/ethnic history

☐ Glucose tolerance test If positive follow Diabetes pathway

☐ Glucose tolerance test If positive follow Diabetes pathway

AT 30-32 WEEKS- Recheck the weight and allocate appropriate care

☐ Weigh at 30 – 32 weeks

☐ Weigh at 30 – 32 weeks ☐ Weigh at 30 – 32 weeks

New weight:

New weight:

New weight:

☐ Refer to Anaesthetist at 32-34 weeks if

co-existing morbidity

☐ Refer to Anaesthetist at 32-34 weeks if

co-existing morbidity or if weight is > 9kg from booking weight

☐ Refer to Anaesthetist at 32- 34 weeks



☐ Advice and support should be given on

the benefits, initiation and maintenance of breastfeeding.

☐ Advice and support should be given on

the benefits, initiation and maintenance of breastfeeding.

☐ Advice and support should be

given on the benefits, initiation and maintenance of breastfeeding.

☐ Scan at 30 and 36 weeks to assess fetal

growth (if no other risk factors). ☐Scan at 30 and 36 weeks to

assess fetal growth (if no other risk factors).

AT 36-38 WEEKS

BMI 30 – 34.9 BMI 35 – 39.9 BMI > 40

☐ Scan (in ANC) to check for

presentation at 36 – 38 weeks if there is doubt.

☐ Scan (in ANC) to check for presentation

at 36 – 38 weeks if there is doubt. ☐ Scan (in ANC) to check for

presentation at 36 – 38 weeks.

☐ Individual documented risk

assessment to determine manual handling requirements for childbirth and consider tissue viability issues.

☐ Consider advising to deliver in the

Delivery Suite (obstetric led). ☐ Should be advised to deliver

in the Delivery Suite (obstetric led). ☐Presentation scan on admission in labour

☐ For labour guidelines

follow the Adagio ☐ For labour follow the Adagio guidelines ☐ For labour follow the Adagio

guidelines



APPENDIX 2 Obesity Management in Pregnancy. Please print and put in patients notes

Patient Sticker CARE Plan for women with BMI > 30

Booking weight:

Booking BMI:

Discussions and actions (please tick when discussed for appropriate BMI)

BMI > 30 BMI >35 BMI > 40 Date and signature

• Information given about exercise

• Information/leaflet re: Pregnancy Plus

• Possible intrapartum complications discussed with consultant and documented

• Thromboembolism • Increased risk of

diabetes/hypertension • Analgesia/anaesthetics

GTT at 28 weeks

See section 8.4

Recheck weight at 30-32 weeks

• Anaesthetic review (BMI > 40

• BMI > 35 if pre-existing comorbidities

• Documented individualised assessment undertaken in 3rd trimester to determine manual handling requirements for labour.

• Discuss tissue viability issues.

Refer to birth options

Midwife if wants to deliver in birth centre.



ANTENATAL CARE MANAGEMENT PLAN

Signature Print Name

Date

Gestational diabetes identified at 28/40? Yes / No If yes, document treatment plan:


Date

INTRAPARTUM CARE MANAGEMENT PLAN

Special equipment required? Yes / No If yes, document details:

Manual handing issues identified? Yes / No If yes, document details:

Tissue viability issues identified? Yes / No If yes, document details:


Date



Appendix 3 Anaesthetic care plan for obese women (BMI > 40). Please print a put in patients hand held notes Date:

Name:

DoB:

Hosp No:

EDD:

Care plan for obese women (BMI > 40) assessment

Summary of care plan • Patient to be reviewed by the duty anaesthetist on arrival on the labour ward for repeat

assessment of airway and review of the plan with the patient. • Consultant anaesthetist must be informed if BMI > 50 • Unless the labour is completely straightforward an epidural should be considered

earlier rather than later as siting might be difficult and take longer than usual • If there is any concern regarding a possible intubation an epidural should be strongly

advised • Water and isotonic sport drinks only during labour • Ranitidine 6 hourly during labour • IV access sited early as it might be difficult, consider insertion of 2nd canula • As this might a difficult delivery inform the consultant on call early. Do not hesitate to

call for help. • If a GA is necessary, call for assistance from the ITU resident while the consultant is

making his/her way in. Make sure all the equipment for difficult intubation is laid out; position the patient in the “ramping position”. Give sodium Citrate 30mls.

Mother intentions for analgesia in labour before the consultation:

o Open minded

o Would prefer an epidural if possible o Would prefer not to have

an epidural o Does not want an epidural at all o If LSCS needed

would prefer to stay awake o If LSCS needed would prefer to be

asleep o Medical history

Allergies: Previous anaesthetic history: Past obstetric history: (Including PPH, retained placenta, LSCS when/how/depth of epidural space…) Present obstetric history: Booking data: Weight ……… Height ……… BMI …………. BP: …………. Week ………/40



Today’s data: Weight ……… Height ……… BMI …………. BP: …………. Week ………/40 Problems during this pregnancy: Clinical examination: CVS: RS: Airway assessment:

o Dental status: o Mallampati grade: o Jaw protrusion: o Neck

movements: o Thyromental distance:

o Neck circumference ………………(>40cm = increase risk of difficult

intubation) Intubation thought to be: Easy Fairly easy Possibly difficult Difficult Very difficult For any of the last three options please make sure that all anaesthetists involved with labour ward are aware and discuss the case with Dr Iossifidis or one of the obstetric anaesthetists. Back assessment: Spinous processes and spaces

o Palpable o Barely palpable o Not palpable o Important fat pad

Scoliosis / other Ultrasound assessment if possible: Thickness of the fat pad …………… Depth of the epidural space ………….. Comments: Venous access: easy difficult Investigations required: (e.g. Echocardiogram, ECG….)

Points covered during the discussion: o Increased BMI may make the need for obstetric intervention and

therefore anaesthetic more likely (rate of LSCS is twice that of a woman of

the same age with a BMI 20-25) o Increased BMI may make the insertion of a spinal or an epidural more

difficult than usual o Increased BMI may make general anaesthesia more difficult especially

intubation o Explanation of procedure and risks associated with

spinal/epidural Plan agreed with the patient: Non negotiable points for the patient: OAA Information leaflets given to the patient:

o Why do I need to see an anaesthetist o Pain relief in labour

o Caesarean Section: Your choice of anaesthesia o Intra-operative cell

salvage in obstetrics Conclusion:

o Woman happy with the plan o

o Woman wishes to go away and think about it



o Disagrees with the plan

o Case discussed with the consultant obstetrician (email) o Plan in

orange notes and in the high risk anaesthetic folder. Signed: Date: