Obesity 8n Obstetric

Question 1

Classification of weigh

Answer 1

BMI
< 18.5 underweight 
18.5-24.9 average 
25-29.9 overweight 
>30 obese
30-34.9 class 1
35-39.9 class 2
>40 class 3

Question 2

Weight gain guidelines in pregnancy

Answer 2

Normal weight 11-16kg
Overweight 7-11.5kg
Obese 5-9kg

Question 3

RCOG GREEN TOP GUIDELINES : primary prepregnancy care

Answer 3

Primary care services should ensure that all women of childbearing age have the opportunity to
optimise their weight before pregnancy. Advice on weight and lifestyle should be given during preconception counselling or contraceptive consultations. Weight and BMI should be measured to encourage women to optimise their weight before pregnancy.

Question 4

RCOG GREEN TOP GUIDELINES :

Answer 4

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).

Question 5

RCOG GREEN TOP GUIDELINES :

Answer 5

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.

Question 6

RCOG GREEN TOP

Answer 6

Women with a BMI 30 kg/m2 or greater wishing to become pregnant should be advised to take 5 mg folic acid supplementation daily, starting at least 1 month before conception and continuing during the first trimester of pregnancy

Answer 7

Obese women are at high risk of vitamin D deficiency. However, although vitamin D
supplementation may ensure that women are vitamin D replete, the evidence on whether routine
vitamin D should be given to improve maternal and offspring outcomes remains uncertain.

Question 8

RCOG GREEN TOP GUIDELINES :

Answer 8

Care of women with obesity in pregnancy can be integrated into all antenatal clinics, with clear
local policies and guidelines for care available.

Question 9

RCOG GREEN TOP GUIDELINES :

Answer 9

This risk assessment should address the following issues:
P
circulation space
accessibility, including doorway widths and thresholds
safe working loads of equipment and floors
appropriate theatre gowns
equipment storage
transportation
staffing levels
availability of, and procurement process for, specific equipment, including large blood
pressure cuffs, appropriately sized compression stockings and pneumatic compression
devices, sit-on weighing scale, large chairs without arms, large wheelchairs, ultrasound scan
couches, ward and delivery beds, mattresses, theatre trolleys, operating theatre tables, and
lifting and lateral transfer equipment.

Answer 10

Maternity units should have a central list of all facilities and equipment required to provide
safe care to pregnant women with a booking BMI 30 kg/m2 or greater. The list should include
details of safe working loads, product dimensions, as well as where specific equipment is
located and how to access it.

Answer 11

Women with a booking BMI 40 kg/m2 for whom moving and handling is likely to prove
unusually difficult should have a moving and handling risk assessment carried out in the third
trimester of pregnancy to determine any requirements for labour and birth. Clear
communication of manual handling requirements should occur between the labour and theatre
suites when women are in early labour

Answer 12

Some women with a booking BMI less than 40 kg/m2 or greater may also benefit from assessment
of moving and handling requirements in the third trimester. This should be decided on an individual
basis.

Answer 13

All pregnant women should have their weight and height measured using appropriate
equipment, and their BMI calculated at the antenatal booking visit. Measurements should be
recorded in the handheld notes and electronic patient information system.

Answer 14

For women with obesity in pregnancy, consideration should be given to reweighing women
during the third trimester to allow appropriate plans to be made for equipment and personnel
required during labour and birth.

Answer 15

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.

Answer 16

All pregnant women with a booking BMI 30 kg/m2 or greater should be provided with accurate
and accessible information about the risks associated with obesity in pregnancy and how they
may be minimised. Women should be given the opportunity to discuss this information.

Answer 17

Dietetic advice by an appropriately trained professional should be provided early in the
pregnancy where possible in line with NICE Public Health Guideline 27.

Answer 18

Anti-obesity or weight loss drugs are not recommended for use in pregnancy.

Answer 19

Pregnant women with a booking BMI 40 kg/m2 or greater should be referred to an obstetric
anaesthetist for consideration of antenatal assessment.

Answer 20

Difficulties with venous access, and regional and general anaesthesia should be assessed. In
addition, an anaesthetic management plan for labour and birth should be discussed and
documented. Multidisciplinary discussion and planning should occur where significant potential
difficulties are identified.

Answer 21

Women with a booking BMI 40 kg/m2 or greater should have a documented risk assessment in
the third trimester of pregnancy by an appropriately qualified professional to consider tissue
viability issues. This should involve the use of a validated scale to support clinical judgement.

Answer 22

All pregnant women with a booking BMI 30 kg/m2 or greater should be screened for
gestational diabetes according to NICE or Scottish Intercollegiate Guidelines Network (SIGN)
guidelines.

Answer 23

An appropriate size of cuff should be used for blood pressure measurements taken at the
booking visit and all subsequent antenatal consultations. The cuff size used should be
documented in the medical records.

Answer 24

Clinicians should be aware that women with class II obesity and greater have an increased risk
of pre-eclampsia compared with those with a normal BMI.

Answer 25

Women with more than one moderate risk factor (BMI of 35 kg/m2 or greater, first pregnancy,
maternal age of more than 40 years, family history of pre-eclampsia and multiple pregnancy)
may benefit from taking 150 mg aspirin daily from 12 weeks of gestation until birth of the
baby.

Answer 26

Women who develop hypertensive complications should be managed according to the NICE CG107.

Answer 27

Clinicians should be aware that women with a BMI 30 kg/m2 or greater, prepregnancy or at
booking, have a pre-existing risk factor for developing VTE during pregnancy.

Answer 28

Risk assessment should be individually discussed, assessed and documented at the first
antenatal visit, during pregnancy (if admitted or develop intercurrent problems), intrapartum
and postpartum. Antenatal and postbirth thromboprophylaxis should be considered in
accordance with the RCOG GTG No. 37a.

Answer 29

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.

Answer 30

There is insufficient evidence to recommend a specific lifestyle intervention to prevent
depression and anxiety in obese pregnant women.

Answer 31

All women should be offered antenatal screening for chromosomal anomalies. Women should
be counselled, however, that some forms of screening for chromosomal anomalies are slightly
less effective with a raised BMI.

Answer 32

Consider the use of transvaginal ultrasound in women in whom it is difficult to obtain nuchal
translucency (NT) measurements transabdominally.

Answer 33

Screening and diagnostic tests for structural anomalies, despite their limitations in the obese
population, should be offered. However, women should be counselled that all forms of
screening for structural anomalies are more limited in obese pregnant women.

Answer 34

As recommended by RCOG GTG No. 31, serial measurement of symphysis fundal height (SFH) is
recommended at each antenatal appointment from 24 weeks of gestation as this improves the
prediction of a small-for-gestational-age fetus.

Answer 35

Women with a BMI greater than 35 kg/m2 are more likely to have inaccurate SFH
measurements and should be referred for serial assessment of fetal size using ultrasound.

Answer 36

Where external palpation is technically difficult or impossible to assess fetal presentation,
ultrasound can be considered as an alternative or complementary method.

Answer 37

In the absence of good-quality evidence, intrapartum fetal monitoring for obese women in
labour should be provided in accordance with NICE CG190 recommendations.

Answer 38

There is a lack of definitive data to recommend routine monitoring of post dates pregnancy.
However, obese pregnant women should be made aware that they are at increased risk of
stillbirth.

Answer 39

Women with maternal obesity should have an informed discussion with their obstetrician and
anaesthetist (if clinically indicated) about a plan for labour and birth which should be
documented in their antenatal notes

Answer 40

Women who are multiparous and otherwise low risk can be offered choice of setting for
planning their birth in MLUs with clear referral pathways for early recourse to CLUs if
complications arise.

Answer 41

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

Answer 42

The decision for a woman with maternal obesity to give birth by planned caesarean section
should involve a multidisciplinary approach, taking into consideration the individual woman’s
comorbidities, antenatal complications and wishes.

Answer 43

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.

Answer 44

Women with a booking BMI 30 kg/m2 or greater should have an individualised decision for
VBAC following informed discussion and consideration of all relevant clinical factors.

Answer 45

Class I and II maternal obesity is not a reason in itself for advising birth within a CLU, but
indicates that further consideration of birth setting may be required.

Answer 46

The additional intrapartum risks of maternal obesity and the additional care that can be
provided in a CLU should be discussed with the woman so that she can make an informed
choice about planned place of birth.

Answer 47

The on-duty anaesthetist covering the labour ward should be informed of all women with class
III obesity admitted to the labour ward for birth. This communication should be documented by
the attending midwife in the notes.

Answer 48

Women with class III obesity who are in established labour should receive continuous
midwifery care, with consideration of additional measures to prevent pressure sores and
monitor the fetal condition.

Answer 49

In the absence of current evidence, intrapartum care should be provided in accordance with
NICE CG190.

Answer 50

Women with a BMI 40 kg/m2 or greater should have venous access established early in labour
and consideration should be given to the siting of a second cannula.

Answer 51

Although active management of the third stage of labour is advised for all women, the
increased risk of PPH in those with a BMI greater than 30 kg/m2 makes this even more
important.

Answer 52

There is a paucity of high-quality evidence to support the use of one surgical approach over
another. Surgical approaches should therefore follow NICE CG132 but clinicians may decide
alternative approaches are merited depending on individual circumstances.

Answer 53

Women with class I obesity or greater having a caesarean section are at increased risk of
wound infection and should receive prophylactic antibiotics at the time of surgery.

Answer 54

Women undergoing caesarean section who have more than 2 cm subcutaneous fat should have
suturing of the subcutaneous tissue space in order to reduce the risk of wound infection and
wound separation.

Answer 55

There is a lack of good-quality evidence to recommend the routine use of negative pressure
dressing therapy, barrier retractors and insertion of subcutaneous drains to reduce the risk of
wound infection in obese women requiring caesarean sections.

Answer 56

Obesity is associated with low breastfeeding initiation and maintenance rates. Women with a
booking BMI 30 kg/m2 or greater should receive appropriate specialist advice and support
antenatally and postnatally regarding the benefits, initiation and maintenance of breastfeeding.

Answer 57

Maternal obesity should be considered when making the decision regarding the most
appropriate form of postnatal contraception.

Answer 58

Refer to NICE CG189. Women with class I obesity or greater at booking should continue to be
offered nutritional advice following childbirth from an appropriately trained professional, with a
view to weight reduction in line with NICE Public health guideline 27.

Answer 59

Women who have been diagnosed with gestational diabetes should have postnatal follow-up in
line with NICE Guideline 3.

Answer 60

Women should be supported to lose weight postpartum and offered referral to weight
management services where these are available.

Answer 61

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

Answer 62

Women with previous bariatric surgery have high-risk pregnancies and should have consultant-
led antenatal care.

Answer 63

Women with previous bariatric surgery should have nutritional surveillance and screening for
deficiencies during pregnancy.

Answer 64

Woman with previous bariatric surgery should be referred to a dietician for advice with regard
to their specialised nutritional needs.

Question 65

Anaesthetic implications of obesity in pregnancy on airway

Answer 65

• failure to intubation 1:280 none obese pregnant
• 1:3 in obese pregnant
• Thorough assessment of airway
• Proper planning

Question 66

Anaesthetic implications of obesity in pregnancy on respiratory system

Answer 66

Reduced FRC 25% non obese may be exaggerated in 9bese
^ incidence OSA + Asthma
^ work of breathing exaggerated by restrictive pulmonary disease in pregnancy
^ incidence of PH and cor pulmonale in obese
^ risk of atelectasis and hypoxia

Question 67

Anaesthetic implications of obesity in pregnancy on cardiovascular system

Answer 67

Pregnancy ^ HR, SV,CO,PULSE P- these maybe poorly tolerated when there is IHD, HPT, CCF Which are associated with obesity
Exaggeration of aortocaval compression

Question 68

Anaesthetic implications of obesity in pregnancy on gastrointestinal system

Answer 68

Large gastric volume
Same aspiration prophylaxis as normal WY
Consider routine 6hrly ranitidine

Question 69

Anaesthetic implications of obesity in pregnancy on

Answer 69

Equipment
Monitoring - aline
Pressure points protection
Thromboprophylaxis

Question 70

Practical consideration of obese obstetric patient

Answer 70

ANC anaesthetic visit

Question 71

Labour Analgesia

Answer 71

Secure venous access should be established early in labour
discuss and offer early epidural analgesia.
dural puncture is significantly increased compared
with normal weight mothers—4% compared with 0.5–2.5%,
respectively.
pre-puncture lumbar ultrasound
patient-
controlled i.v. remifentanil analgesia offers a reasonable alternative
if epidural analgesia is contraindicated or has failed.
supplemental oxygen entenox

Question 72

Anaesthesia for cesarean section: regional

Answer 72

requirement for local anaesthetic is less

Epidural anaesthesia may be advantageous

Question 73

Anaesthesia for cesarean section:

Answer 73

‘sniffing

the morning air’ intubation position to the ‘ramped’ position

Question 74

Anaesthesia for cesarean section: post operative care.

Answer 74

increased risk of hypoxe-

mia, chest infection, wound infection, and deep venous thrombosis.