16.5 Obese Parturient Flashcards
A primiparous patient with a booking BMI of 55 kg/m2 presents in the high-risk obstetric anaesthetic
assessment clinic at 32-weeks gestation. She is hoping for a vaginal delivery.
a) Which specific points do you need to elicit from the history and examination? (30%)
Airway:
» History of difficult airway.
» History of problems with anaesthesia in the past.
» Perform airway assessment.
Respiratory:
» History of obstructive sleep apnoea.
» History of other respiratory symptoms
such as dyspnoea or asthma.
» Check oxygen saturations when
supine and auscultate chest.
Cardiovascular:
» Assess exercise tolerance.
> > Check for history or symptoms
of ischaemic heart disease.
> > Check blood pressure.
> > Assess for likely ease of cannulation.
Endocrine:
» Check for history of diabetes mellitus or gestational diabetes and check
medications and control.
Pharmacology:
» Document all medications.
> > May be taking low-molecular-weight heparin,
which has impact on the
timing of neuraxial techniques.
Gastrointestinal:
» History of reflux and medications to control this.
Cutaneomusculoskeletal:
» Check weight – consider impact on equipment, theatre table.
» Assess for ability of woman to position herself for neuraxial technique.
Obstetric:
» Check for problems with pregnancy.
b) What do you need to communicate to the patient? (35%)
> > Reason for referral:
raised BMI increases likelihood of
needing caesarean
or instrumental delivery,
and therefore, there is an increased
likelihood of an anaesthetist being
involved in their care.
> > Recommendation to avoid
eating and to drink only clear fluids in labour,
in view of the increased risk of
needing assistance with delivery
and, therefore, some form of anaesthesia.
This reduces the likelihood of
aspiration of particulate stomach content.
> > Regular antacid in labour for
same reason as earlier, to reduce the risk of
aspiration of highly acidic stomach content.
> > Epidural and spinal may be
more difficult to do and take longer.
> > Consider early epidural,
especially if labour is not progressing well:
easier to perform in early rather
than advanced labour and can be topped up
for the purposes of caesarean or instrumental delivery, thus possibly reducing the need for general anaesthesia.
> > General anaesthetic may be more difficult
to perform and may have
increased risks.
Optimum care of mother and baby
is for the mother to
remain awake
(with neuraxial anaesthesia if necessary)
for delivery.
c) Document your plan for her management on the delivery suite. (35%)
My documentation would include the following points:
> > BMI and weight.
> > Outcomes from clinic meeting,
including any issues elicited from history
and examination.
> > Airway assessment,
predicted difficulty with neuraxial block and any
predicted issues with cannulation.
> > If woman currently taking
low-molecular-weight heparin,
give clear advice
regarding omission of dose
if any chance that she is in early labour, to
consult delivery suite early for assessment and admission if indicated.
> > Any specific equipment requirements.
> > Instruction to alert anaesthetist
on arrival in labour,
junior anaesthetist to contact consultant.
> > Early cannula?
Depends on consultation with
the woman and her
individual risks.
> > Early epidural? Depends on
consultation with the woman.
> > Instruction to restrict oral
intake to clear fluids only in labour and regular
ranitidine to be given.
> > Thromboembolic deterrent
stockings to be worn in labour,
consideration of low-molecular-weight heparin prophylaxis afterwards as per guideline
(ensure dose appropriate to patient weight).
