You've just been notified that a pregnant woman weighing over 600 pounds will be giving birth in your unit next week. What plans should be underway to make sure this birth is as safe as possible? Key issues to consider for women with extreme obesity (body mass index > 40) are (a) the nurse-to-patient ratio, (b) maternal and fetal assessment, (c) pain management, (d) necessary equipment, and (e) possible emergent cesarean birth.
Advance planning is critical to safe care during labor and birth for women with extreme obesity. Ideally, each perinatal unit has established protocols for these pregnant women that include advance notification from providers by 34 weeks gestation. Although an estimated maternal weight can be useful for planning purposes, maternal weight should be confirmed on admission if at all possible because an accurate weight determines the type of bed that is required. If a woman is ambulatory and there is no scale that can provide an accurate weight for patients over 300 pounds (accuracy limit of most scales), it may be necessary to escort her to a scale that the hospital normally uses to weigh freight or laundry. This can be embarrassing for the woman, and the situation should be handled in a manner most sensitive to her situation.
A woman with special needs based on her weight likely requires, at a minimum, one nurse who stays at the bedside continuously during labor; however, during the active pushing phase and during the birth, more nurses are needed. Accurate continuous maternal-fetal assessment via EFM also may be a challenge, and it may be necessary to manually hold the external ultrasound transducer in place continuously to maintain a fetal monitoring tracing. Two belts can be tied together to achieve the necessary length required to secure the external tocotransducer. If pharmacologic agents are used for cervical ripening and labor induction, care should be taken to accurately monitor uterine activity to promptly identify and treat hyperstimulation if it occurs. As labor progresses, internal monitoring may be the best option for obtaining a continuous tracing. A large blood pressure cuff should be available to assess maternal blood pressure.
The anesthesia provider should be involved in the advance planning process and ideally conduct a preanesthesia assessment before admission for labor. If regional anesthesia is desired, be prepared for the possibility of a difficult insertion of the epidural catheter. Before administering regional anesthesia, an air cushion mattress specifically designed to transfer extremely obese patients can be placed on the bed to assist in moving the woman to a surgical table in the case of cesarean birth.
Five hundred pounds is the maximum weight that most beds can safely handle, so a bariatric bed with appropriate weight limits should be available (generally available for patient weights from 600-1,000 pounds). Manufacturer recommendations for these beds need to be followed, because some positions (such as semi-Fowlers) could alter the physics of bed stability and increase the risk that the bed may tip over if raised at an angle higher than manufacturer recommendations. Because stirrups are not routinely available for all bariatric beds, it may be difficult for the provider to have enough space for visualizing the perineum during birth and suturing an episiotomy and conducting required maneuvers should a shoulder dystocia occur.
One option is to plan for the birth to occur in the surgical suite, because surgical tables can usually accommodate weights up to 1,000 pounds, but confirm the weight limits of the tables in your unit. Surgical tables, however, are particularly sensitive to changes in weight distribution associated with positions for birth, thus a semi-Fowler's position may not be possible in all cases, even with pillow or clinician support, based on the woman's weight. The stirrups usually used for the surgical table most likely will not safely hold the weight of the legs of this patient; thus, two clinicians holding each leg may be necessary. Montgomery straps can be useful for holding the panniculus adiposis away from the perineum. Large retractors may be necessary to assist with inspection of the birth canal after birth and adequate visualization of the perineum if suturing is required. If an unexpected or emergent cesarean birth is required, surgical table extenders can provide an additional 6- to 8-inch width. Remember that bariatric beds are wider than birthing beds, so make sure in advance that the bariatric bed can fit through the surgical suite door frame.
Advance Planning for Labor and Birth of Extremely Obese Pregnant Women
* Advanced notification by provider to L&D about special needs patient
* Special sensitivity to woman's emotional needs and possible embarrassment
* Accurate weight assessment on admission if possible
* Adequate nurse to patient ratio, especially in second stage
* Belt extenders for maternal-fetal assessment
* Appropriately large equipment, including B/P cuff, bariatric bed, and surgical table extenders
* Advanced planning for pain management and anesthesia consult
* Plans for possible emergent cesarean birth