Evidence Based
Approach to Cesarean
Delivery in the Obese
Gravida
Objectives
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Name 3 comorbidities associated with
obesity in the general population and 2
additional comorbidities associated with
obesity in the pregnant population.
Name 3 measures that can be taken
preoperatively to decrease morbidity during
a C-Section
Name 2 measure that can be taken
intraoperatively to decrease morbidity during
a C-Section
Definition of Obesity
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Definition
Obesity Class
BMI (kg/m2)
Underweight
BMI<18.5
Normal
BMI 18.5-24.9
Overweight
BMI 25.0-29.9
Obese
BMI 30.0-34.9
Class I
BMI 35.0-39.9
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Class II
Extreme Obesity
Class III
BMI >40
Epidemiology of Obesity
Epidemiology of pregnant
population
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In one 2007 Californian study (Kim et al) it
was found that >40% of women are
overweight or obese when initiating
pregnancy
A 2006 study (Johnson et al) looking at a US
database showed 25% incidence of obesity
when initiating pregnancy
In a 1999 study (lu et al)
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25% of women >200 lbs at first PNV
10% >250 lbs
5% >300 lbs
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Risks of Obesity in General
Population
CAD, HTN, hyperlipidemia
DM Type II
Obesity hypoventilation syndrome, OSA,
Asthma
GERD
Fatty Liver, Cholelithiasis, NASH, Cirrhosis
Stress urinary incontinence
Venous stasis, DVTs, PEs
Hernias
Infection (cellulitis, post-op wound infections)
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Risks of Obesity in Pregnancy
Increased miscarriages
GDM
GHTN, PreE
Prolonged hospitalization
UTIs
Dysfunctional Labor
Hemorrhage
Increased rates of C-sections
Perioperative Risks
Fetal Risks
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Preterm Deliveries
Post Term Pregnancy
Lower Apgar Scores
IUGR
Macrosomia & shoulder dystocia
NICU admissions
neonatal and childhood obesity
Congenital malformations (spina bifida,
omphalocele, heart defects)
Increased incidence of C/S
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European prospective study with more than
200,000 deliveries a BMI >40 was
associated with 4 times risk of C/S.
Cedergren MI et al
Another study C/S for nonobese was 20.7%,
compared with 33.8% for obese (BMI 3034.9) and 50% for extremely obese
(BMI>35) Wiess JL et al.
Increase in Emergent C-Sections. Poobalan
AS et al.
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Overwieght OR 1.53
Perioperative morbidities
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Prolonged operative time
Increased Blood Loss
Fe in PNC
o T&C
o H/H before OR
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Increased risk of thromboembolism
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Thrombopyphylaxis
Aspiration/Failed intubation
Anesthetic Morbidities
Anesthesia Considerations
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75% of all anesthesia-related maternal
deaths happened in obese pts
o Difficult placement of IV access
o Difficult achieving endotracheal airway
 Pts more quickly desaturate
o Difficulty placing epidural/spinal
 Pt can't flex back as well
 More tissue to go through
 Importance of prophylactic CSE
o Aspiration Prophylaxis
 Bicitra
 Consider NPO in labor
Prophylactic antibiotics
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Review of 66 trials showed prophylactic abx
reduces risk of infection up to 75%. Smaill
et. al (Level A)
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Study with bariatric pts showed inadequate abx
levels in obese pts receiving 2 g of ancef (Edmiston
et al)
Thromboembolic prophylaxis
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One of the leading causes of maternal death
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Occurs more frequently in obese pts
SCDs Pre and postoperatively (Level C)
If BMI>40 Unfractionated Heparin 500010000 u q 8-12 hrs
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No well designed RTCs to assess risk reduction
therefore recommendations is expert opinion (Level
C)
Importance of team approach
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Appropriately trained OR staff
Surgical assistant(s)
Anesthesiology staff trained in fiberoptic
intubation
Equipment
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Bariatric set
Alexis retractor
Vacuum
elastoplast tape or Montgomery straps
What to do with the Pannus?
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Incision Choice
Lack of randomized control studies.
Vertical incision
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12 fold greater risk of wound complications compared to
transverse
Rapid, Easy to extend
Transverse Incision
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Low
 warm moist area under pannus
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Cephalad retraction of pannus
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thought to increase risk of infection
May lead to cardiopulmonary comprimise
Perumbilical/Supraumbilical
 Avoid button hole
 Avoid using the umbilicus as a landmark
Intraoperative Considerations
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Self retaining retractor
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Alexis retractor
Fundal pressure often difficult and limited
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Have vacuum available
Closure
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1 or 2 delayed absorbable monofilament
suture on facia.
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Fascial stitch should incorporate >1cm of facia and
stitch interval no <1 cm apart
Consider Mass closure (Smead Jones Technique)
Subcutaneous Suture
o In a 2004 metanalysis (Chelmow et al)34%
decrease in risk of wound complications with
subcutatneous sutures when subcutaneous tissue
>2cm (Grade A)
Drains
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No additional benefit (Grade A)
Staples vs subcuticular
Smead Jones Closure
Post operative morbidities
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10 fold increase in post-operative endometritis
Higher rates of wound infection
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Close inspection of wound
Consider removing staples after discharge in office esp
with vertical incision
Increased risk of thromboembolism
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Encourage early ambulation
Postpartum weight retention
Encourage breast feeding
o Nutrition counseling
o Consider bariatric consult
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Higher rates of PP depression
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40% with Class III obesity
Sources
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Gunatilake RP, Perlow JH. Obesity and pregnancy: clinical management of the obese gravida. Am J Obstet Gynecol
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Perlow, Jordan H. "Chapter 6: Obesity in the Obstetric Intensive Care Patient." Obstetric Intensive Care Manual. 3rd ed.
New York: McGraw Hill, 2011. 61-72. Print.
Beattie PG, Rings TR, Hunter MF, Lake Y. Risk factors for wound infection following Cesarean Section. Aust N Z J Obstet
Gynaecol. 1994;34:398-402
http://www.cdc.gov/obesity/data/trends.html
Kim SY, Dietz PM, England L, Morrow B, Calligan WM, Trends in pre-pregnancy obesity in nine states, 1993-2003.
Obesity (Silver Spring) 2007; 15:986-93
Lu GC, Rouse DJ, Dubard M, Cliver S, Kimberlin D, hauth JC. The effect of the increasing prevalence of maternal obesity
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Weiss JL, Malone FD, Emig D, et al. Obesity, obstetric complications and cesarean delivery rate: a population-based
screening study. Am J Obstet Gynecol 2004;190:1091-1097.
Cedergren MI. Non-elective caesarean delivery due to ineffective uterine contractility or due to obstructed labour in relation
to maternal body mass index. Eur J Obstet Gynecol Reprod Biol 2009;145:163-166.
Vallejo MC. Anesthetic management of the morbidly obese parturient. Curr Opin Anaesthesiol 2007;20:175-180.
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