Policy for Management Of

WAHT- OBS-096 This guideline has been printed from the Worcestershire Acute Hospitals NHS Trust intranet on 28/04/2018,13:12 It is the responsibility of every individual to check that this is the latest version/copy of this document.

MANAGEMENT OF THE OBESE WOMAN IN PREGNANCY

This guidance does not override the individual responsibility of health professionals to make appropriate decision according to the circumstances of the individual patient in consultation with the patient and /or carer. Health care professionals must be prepared to justify any deviation from this guidance.

INTRODUCTION Obesity is a risk factor for maternal morbidity and mortality. Hospital and community risk assessment should be undertaken as part of the care plan for all obese women. This guideline is to assist all professionals to make such care plans for obese women with any associated co-morbidity (any other relevant medical conditions) and women with BMI of 35 and above with or without co-morbidity. Please use in conjunction with thromboprophylaxis guideline WAHT-OBS-012.

THIS GUIDELINE IS FOR USE BY THE FOLLOWING STAFF GROUPS : Midwives, obstetricians, anaesthetists, manual handling and tissue viability staff

Lead Clinician(s) Miss Rabia Imtiaz Consultant Obstetrician Judi Barratt Clinical Midwife Specialist Dr R Alexander Consultant Anaesthetist Approved by Obstetric Guidelines Group on: 18 January 2013 This guideline should not be used after end of: 18 January 2015

Key amendments to this guideline Date Amendment By: 19.08.11 Clarification of scanning and care planning arrangements – agreed R Imtiaz by Obstetric Clinical Governance-Risk Management J A Barratt Committee 18.01.2013 Women with BMI>40 should have a documented 3rd trimester R Imtiaz assessment of tissue viability issues/concerns, a notification R Duckett to the LW manager, and MDT plan if BMI >50. Postnatally, they should have an assessment of wounds before discharge. Women with concerns identified at discharge or identified as a tissue viability risk during pregnancy should be seen by the tissue viability team before discharge. Clarification experienced obstetrician to review women with BMI >40 in third trimester

Management of the obese women in pregnancy WAHT-OBS-096 Page 1 of 13 Version 4 WAHT- OBS-096 This guideline has been printed from the Worcestershire Acute Hospitals NHS Trust intranet on 28/04/2018,13:12 It is the responsibility of every individual to check that this is the latest version/copy of this document. MANAGEMENT OF THE OBESE WOMAN IN PREGNANCY

INTRODUCTION To ensure that the risks for severely overweight women are reduced it is important that a multidisciplinary plan of care is made, which includes risk assessment for all stages of pregnancy birth and in the postnatal period. All women should have their BMI calculated and recorded on their customised antenatal growth chart. The BMI should be calculated and documented in the electronic patient information system at booking. The body mass index (BMI) is the most commonly used measure of obesity. It looks at weight in relation to height, and is defined as weight in kilograms divided by height in metres. Adults with a BMI of between 25 and 30 inclusive are deemed to be overweight and those with a BMI over 30 are seen as obese. BMI recordings of between 20 and 25 are seen to represent healthy (or normal) weight. Those with a BMI of ≥35 are morbidly obese (class II), BMI ≥ 40 (class III). (See appendix 2 for WHO obesity classes.) While acknowledging the need for sensitivity in discussing her plan of care it is essential that the obese woman understands the risks associated with her pregnancy including the fact that routine monitoring of her baby by measuring symphysis pubic height (SFH) is not reliable and in some women who have class II or III obesity difficulty in measuring fetal growth via ultrasound may also be experienced.

DETAILS OF GUIDELINE

The following risks / co-morbidities are associated with obesity (BMI>30) and they should be discussed with the woman in the antenatal period by either the obstetrician or community midwife: Antenatal Risks:  Hypertensive disorders (including pre-existing hypertension and pregnancy – induced hypertension)  Gestational diabetes  Urinary tract infections  Thromboembolism  Difficulty in assessment of fetal growth  Macrosomia  Increased risk of undetected fetal abnormality as ultrasound scan view sub-optimal Intrapartum risks  Postpartum haemorrhage  Shoulder dystocia  Difficulty in undertaking fetal monitoring by cardiotocograph  Increased risk of repeat caesarean section  Increased risks associated with anaesthetic, both general and local

Antenatal Management  All women with a BMI of 30-35 are classed as obese and have a high risk of VTE. These women should be booked by community midwives for midwifery led care unless following VTE risk assessment they are classed as high risk or have any other comorbidities, in which case they should be referred for consultant booking.

Management of the obese women in pregnancy WAHT-OBS-096 Page 2 of 13 Version 4 WAHT- OBS-096 This guideline has been printed from the Worcestershire Acute Hospitals NHS Trust intranet on 28/04/2018,13:12 It is the responsibility of every individual to check that this is the latest version/copy of this document.

 At booking the woman should be given advice re healthy eating and regular exercise.  All pregnant women with a BMI of ≥ 35 must be booked for delivery in hospital under the care of an obstetric consultant.  Discuss the risks of obesity in pregnancy, labour and delivery as detailed above.  All women with grade III obesity (BMI>40) should have an individual assessment in the 3rd trimester of pregnancy which should be clearly documented in the health records, see below.  Blood Pressure should always be recorded using a large cuff.  Examine urine at each antenatal visit and send for culture to screen for asymptomatic bacteriuria at booking.  Symphysis fundal height measurements are unreliable in most obese women. Therefore the assessment of fetal growth by ultrasound scan in the third trimester will most likely be required. The frequency of ultrasound scan will depend on the BMI and other comorbidities. This, in most cases, would involve at least two growth scans in the third trimester. Further ultrasound scans can be requested on an individual basis if clinically indicated.  Risk of developing Gestational diabetes: In obese women, the risk of developing gestational diabetes is significantly more than in women of normal weight. All women with BMI of 35 or more should have a glucose tolerance test at 28 weeks gestation.

 Venous Thromboprophylaxis: Risk assessment for VTE should be undertaken at the booking visit. (WAHT-OBS-012 Risk assessment tool - Appendix 1).

What is the risk for women with high BMI? o Women with BMI more than 30 are at increased risk of developing DVT or PE in pregnancy. o Women with BMI >40- get a risk score of 2 during booking assessment. If they have any other pre existing risk factors like age >35 years, parity >3 they receive antenatal thromboprophylaxis. o Women with BMI>45 – The decision for antenatal thromboprophylaxis must be made on an individual basis. Other risk factors like smoking, sedentary life style should be considered.  Hypertensive disorders of pregnancy: In pregnancy obese women have higher blood pressures and altered cardiac function. There is an increased risk of pre- eclampsia and eclampsia among women of high body mass indices. Regular monitoring of blood pressure and urine for protein is suggested .  A referral to the obstetric anaesthetic clinic should be made for all women with BMI >40. In certain cases women may need to be referred where BMI may be <40 i.e. when there is marked central obesity, or short neck or small chin and in presence of co-morbidity. The clearly documented plan of care made by anaesthetist should be kept in the woman’s health record.  Mode of delivery: For obese women who have had a previous LSCS VBAC may be feasible, but each woman must be reviewed on an individual basis by the named obstetric consultant.  For all women a plan should be made by the consultant obstetrician regarding delivery. Elective lower segment caesarean section should be planned for obstetric indications only.

Antenatal management of Women with BMI>40

Women with BMI >40 should be seen by an experienced Obstetrician (Consultant / or ST5 or above trainee) at least once in the third trimester to review regarding tissue viability, manual handling issues and discuss the plans for labour /delivery.  All women with grade III obesity should have an individual assessment in the 3rd trimester of pregnancy, and a multi-disciplinary plan of care should be made including all relevant staff who should be involved, in particular anaesthetic consultant. The documented obstetric management plan for labour and delivery should be kept in the woman’s pregnancy health record. The plan should be comprehensive enough to be implemented in an emergency.

 Tissue viability issues/concerns should be assessed during antenatal consultation by addressing following: o Are there any problem skin area? o Any history of previous wound infection? If there is tissue viability issues identified contact the Tissue Viability Team for advice. The tissue viability team may wish to review the patient or advise appropriately. Have a low threshold to discuss women with BMI>40 with the tissue viability team if any other concerns/risk factors for poor would healing.

 Labour ward is informed about the EDD/ date of IOL/ CS if booked so appropriate arrangements can be made for necessary bariatric equipment. This is done by entering the women’s details on Obesity Database and highlighting on Caesarean section / IOL diary while booking IOL/delivery so necessary bariatric equipment can be made ready.

 A referral to the obstetric anaesthetic clinic should be made for all women with BMI >40. In certain cases women may need to be referred where BMI may be <40 i.e. when there is marked central obesity, or short neck or small chin and in presence of co-morbidity. The clearly documented plan of care made by anaesthetist should be kept in the woman’s health record.

Labour/ Delivery A plan of care should be available in the woman’s pregnancy health record. Please make sure it is followed. If no plan is available, e.g. if the woman is unbooked, the on- call consultant anaesthetist and obstetrician should ensure an emergency plan is drawn up.  The on-call obstetric registrar and anaesthetist should be informed when a women with a BMI ≥35 is admitted in labour.  A risk assessment for labour must be performed with specific attention to the potential development of pre-eclampsia, thromboembolism, shoulder dystocia and PPH.

 Intravenous cannulation is more difficult in obese women. Venous access should be secured early, simultaneously taking blood for full blood count, group and save. Because of the difficulty that may be encountered with cannulation, it is better to undertake this procedure early, rather than during an emergency.

 Women should be cared for as high risk, if any difficulty in monitoring fetal heart rate a fetal scalp electrode (FSE) should be used (following maternal consent).  Progress of labour is recorded as usual with extra awareness of possibility of cephalopelvic disproportion.  Extra vigilance is required to correctly identify degree of perineal trauma following vaginal delivery. Great care must be taken when putting the woman in lithotomy to avoid tissue damage from being in lithotomy position.

Caesarean section  The on-call obstetric registrar should see and examine the woman with a view to assessing the need for additional help. The on-call obstetric consultant should be informed if there are any concerns.  The on-call obstetric consultant should be present for caesarean section of all women with class III or more obesity  Alexis-O abdominal wall retractors should be considered in obese women undergoing caesarean section for better access.  An experienced obstetric anaesthetist should be present for all deliveries in theatre.  In obese women, subcutaneous layer of the abdominal wall should be sutured; it reduces the chance of developing postoperative wound morbidity. Placement of a subcutaneous drain at caesarean section has not proven effective in reducing wound morbidity in obese women  Consider the use of sequential pneumatic stockings in women of BMI ≥40 undergoing caesarean delivery.  Prophylactic antibiotics are essential see WAHT-OBS-097  Risk of PPH: Prophylactic syntocinon infusion 40iu syntocinon in 40mls of normal saline as per WAHT-OBS-030 Management of Massive PPH  Encourage early mobilisation.  Following delivery by LSCS, greater vigilance is required when observing the woman for signs of: o Wound infection o Wound dehiscence o Thromboembolism – either DVT or pulmonary embolism o Chest infection if general anaesthesia

Postnatal care for all women

 Early referral to the physiotherapist is essential. Additional education may be required regarding mobilisation, leg exercises, pelvic floor exercises, hygiene and wound care.  Risk of postnatal depression: Obesity and the postpartum periods are independent risk factors for the development of psychological disorders e.g. depression.  Postnatally women with BMI >40 should have careful assessment of their wounds before discharge.  All women who have concerns identified at discharge or were marked as “tissue viability at risk” should be seen by the Tissue viability team before discharge.

Postnatal Thromboprophylaxis

 Refer to WAHT-OBS-012.

Advice on contraception

 Evidence has shown that as many as 23% of obese women do not use contraceptives. Contraception should be discussed with the woman before discharge.

Preconception:  Women should be advised that control of obesity in the preconception period is an important element of the care. Successful weight management results in significant reduction of maternal and fetal morbidity including caesarean sections, gestational diabetes and late fetal deaths.

Special Bariatric Equipment: After antenatal assessment, any arrangements necessary and a planning meeting may be arranged with the bariatric team on individual basis (BMI cut-off for referral to bariatric services may vary). If an individual plan of care is done with the bariatric team it should be kept in the woman’s health records. Bariatric equipment can be deployed to the unit if necessary e.g. special profile beds, chairs etc. See appendix 1

APPENDIX1:

Manual Handling Plan of Care for the Bariatric Pregnant Women/Mother

Purpose of the following manual handling plan of care is to reduce the risk of injury to the women and clinical staff for the women with increased BMI. Some women may require individual assessment by the bariatric service. If an individual plan of care is done it should be kept in woman’s health records.

Antenatal care - If a woman is admitted to hospital for antenatal care the safe working load (SWL) of the ward bed, chair and commode must be check. If the woman’s weight is higher than the SWL, the following action must be taken.  Hospital bed - King Fund manual bed SWL is 184 kgs (29 stone) if the patient needs assistance in/out of bed or manual handling in bed a electric profiling bed must be obtained If a profiling bed is not available a profiling bed must be hired.  Patient Chair - The SWL of the chair must be checked if the patient exceeds the SWL a Bariatric chair must be obtained. If a bariatric chair is not available a chair must be hired.  Commode - If the women weight exceeds the SWL of the commodes a bariatric commode must be obtained.

For Labour/Delivery  Delivery bed - The safe working load of the delivery bed must be check prior to women delivery date, the SWL will be written on the delivery bed. If the woman exceeds the SWL a delivery bed must be obtained.  Postnatal bed - Please follow the instructions in antenatal care for hospital bed, patient chair and commode.

The size and shape of the women must be considered prior to the woman’s caesarean date. If the woman’s size and shape exceeds the theatre table, extensions for the theatre table must be used to reduce the risk of injury to the women and clinical staff.

Lateral transfer The Hovermatt must be used to laterally transfer the women from the theatre table to the profiling bed, see Hospital bed (Antenatal care). The Hovermatt must be placed on the theatre table prior to the women being transferred on to table, the Hovermatt must only be operated by staff who received training in the uses of the Hovermatt. If the weight or conditions of the women does not require the Hovermatt, a Pat-slide must be used for the transfer. Slide sheets must be used with the Pat-slide. Staff must be trained in the use of Pat-sliding with slide.

Postnatal care following a caesarean - Please follow the instructions in the Antenatal care above - hospital bed, patient’s chair, commode.

APPENDIX 2

The International Classification of adult underweight, overweight and obesity according to BMI

Classification BMI(kg/m²) Principal cut-off Additional cut-off points points Underweight <18.50 <18.50 Severe thinness <16.00 <16.00 Moderate thinness 16.00 - 16.99 16.00 - 16.99 Mild thinness 17.00 - 18.49 17.00 - 18.49 18.50 - 22.99 Normal range 18.50 - 24.99 23.00 - 24.99 Overweight ≥25.00 ≥25.00 25.00 - 27.49 Pre-obese 25.00 - 29.99 27.50 - 29.99 Obese ≥30.00 ≥30.00 30.00 - 32.49 Obese class I 30.00 - 34-99 32.50 - 34.99 35.00 - 37.49 Obese class II 35.00 - 39.99 37.50 - 39.99 Obese class III ≥40.00 ≥40.00 Source: Adapted from WHO, 1995, WHO, 2000 and WHO 2004.

MONITORING TOOL STANDARDS % CLINICAL EXCEPTIONS All women will be weighed and measured at booking. BMI will be 100% Nil calculated and recorded on the grow chart and electronic record. All women with BMI>35 will be booked for consultant care 100% Nil All obese women should have possible intrapartum complications 100% Nil discussed and documented in the health record All women with BMI > 40 should be offered antenatal assessment 100% Nil with the obstetric anaesthetist Documented assessment and plan for manual handling 100% Nil requirements and tissue viability issues for women with a BMI ≥40 in third trimester

How will monitoring be carried out? Audit Who will monitor compliance with the guideline? Obstetric Governance Committee

REFERENCES

Saving Mothers’ Lives, Reviewing maternal deaths to make motherhood safer: 2006–2008 March 2011 CEMACH Perinatal Mortality Surveillance Report 2004 WHO 2004 Albert LL, Greulich B, Peretta P; Body Mass Index, Midwifery Intrapartum Care, and Childbirth Lacerations; Journal of Midwifery and Women’s Health; vol 51, No. 4, July/August 2006. Alexander CI, Liston WA; Operating on the obese woman – a review; BJOG, RCOG August 2006.

CONTRIBUTION LIST Key individuals involved in developing the document Name Designation Miss R Imtiaz Consultant Obstetrician Judi Barratt Clinical Midwife Specialist Circulated to the following individuals for comments Name Designation Mr J F Watts Clinical Director-Consultant Obstetrician/Gynaecologist Mrs P Arya Consultant Obstetrician/Gynaecologist Miss R Duckett Consultant Obstetrician/Gynaecologist Mrs S Ghosh Consultant Obstetrician/Gynaecologist Mr J Hughes Consultant Obstetrician/Gynaecologist Miss J Meggy Consultant Obstetrician/Gynaecologist Mr P A Moran Consultant Obstetrician/Gynaecologist Mr B A Ruparelia Consultant Obstetrician/Gynaecologist Mrs J Shahid Consultant Obstetrician/Gynaecologist Miss D Sinha Consultant Obstetrician/Gynaecologist Mr A Thomson Consultant Obstetrician/Gynaecologist Mr J Uhiara Consultant Obstetrician/Gynaecologist K Kokoska Acting Head of Midwifery A Talbot Senior Midwife/Supervisor of Midwives J Byrne Senior Midwife/Supervisor of Midwives M Stewart Senior Midwife/Supervisor of Midwives A Bennett/F Pagan Delivery Suite Managers, Alexandra Hospital P Jones Delivery Suite Manager, WRH R Fletcher Clinical Pharmacist M Richardson Manual Handling Trainer J Walker Manual Handling Advisor A Latta Manual Handling Advisor Dr S Millett Consultant Anaesthetist Dr H Whibley Consultant Anaesthetist Dr A Stronach Consultant Anaesthetist Sarah Norris Theatre Manager Anne Digby Theatre Manager Shona Massey Sister – Theatres User representatives (LW Forum) C Finneran L Ratcliffe D Stokes S Tyrrell J Willis Members of Guideline Group (For consultation with their peers) J A Barratt Clinical Midwife Specialist (Chair) M Byrne Midwife, Alexandra Hospital T Cooper Consultant Midwife Y Cowling Community Midwife, West Team D Daly Community Lead Leader, Droitwich Team E Davis Transitional Care Unit, WRH H Doherty Community Midwife, Redditch Team J S Farmer Midwife, Antenatal Clinic, WRH G Field/ Community Midwife Team Leader, Bromsgrove Team S Guarnieri Midwife, WRH L Heywood Community Midwife, Evesham Team J Martin Midwife, CDS, Alexandra Hospital T Meredy Midwife, Antenatal Clinic, Alexandra Hospital G Robinson Community Midwife, Worcester City Team S Tabberer Community Midwife Team Leader, Kidderminster A Talbot Matron/Senior Midwife, WRH A Tilley Community Midwife Team Leader, Worcester City V Tristram Midwife, Kidderminster Hospital H Walker Community Midwife, Kidderminster Team R Williams Midwife, Delivery Suite/PN Ward, WRH Circulated to the following CD’s/Heads of dept for comments from their directorates / departments Name Directorate / Department Nalinee Owen Nutrition and Dietetics Manager Dr Steve Digby Clinical Director / Consultant Anaesthetist

Management of the obese women in pregnancy WAHT-OBS-096 Page 11 of 13 Version 4 WAHT- OBS-096 This guideline has been printed from the Worcestershire Acute Hospitals NHS Trust intranet on 28/04/2018,13:12 It is the responsibility of every individual to check that this is the latest version/copy of this document. Supporting Document 1 – Checklist for review and approval of key documents This checklist is designed to be completed whilst a key document is being developed / reviewed.

A completed checklist will need to be returned with the document before it can be published on the intranet.

For documents that are being reviewed and reissued without change, this checklist will still need to be completed, to ensure that the document is in the correct format, has any new documentation included.

1 Type of document Guideline 2 Title of document Management of obese women in pregnancy 3 Is this a new document? Yes No If no, what is the reference number WAHT-OBS-OBS-096 4 For existing documents, have Yes No you included and completed the key amendments box? 5 Owning department Obstetrics 6 Clinical lead/s Miss Rachel Duckett 7 Pharmacist name (required if Rosie Fletcher medication is involved) 8 Has all mandatory content been Yes No included (see relevant document template) 9 If this is a new document have Yes No properly completed Equality Impact and Financial N/A Assessments been included? 10 Please describe the consultation Circulated to members of the Obstetric Governance that has been carried out for this Committees document 11 Please state how you want the Management of obese women in pregnancy title of this document to appear on the intranet, for search purposes and which specialty this document relates to. Once the document has been developed and is ready for approval, send to the Clinical Governance Department, along with this partially completed checklist, for them to check format, mandatory content etc. Once checked, the document and checklist will be submitted to relevant committee for approval.

Implementation Briefly describe the steps that will be taken to ensure that this key document is implemented

Action Person responsible Timescale Information included in Effective Handover Miss Rachel Duckett January 2013

Plan for dissemination

Disseminated to Date Medical and midwifery staff via Effective Handover January 2013

Step 1 To be completed by Clinical Governance 1 Department Is the document in the correct Yes No format?

Has all mandatory content been Yes No included?

Date form returned ____/____/______2 Name of the approving body Obstetric Governance Committee (person or committee/s) Step 2 To be completed by Committee Chair/ Accountable Director 3 Approved by (Name of Chair/ Miss Rabia Imtiaz Accountable Director): 4 Approval date 18 January 2013

Please return an electronic version of the approved document and completed checklist to the Clinical Governance Department, and ensure that a copy of the committee minutes is also provided (or approval email from accountable director in the case of minor amendments).

Office use only Reference Number Date form received Date document Version No. published WAHT-OBS-096 23/01/2013 28/01/2014 4

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