The following guidelines are intended only as a general educational resource for hospitals
and clinicians, and are not intended to reflect or establish a standard of care or to replace
individual clinician judgment and medical decision making for specific healthcare
environments and patient situations.
GUIDELINE FOR THE CARE OF THE OBESE PATIENT
February, 2012
Preconception Period
 Screening
o Identify obese patients, record BMI on chart Level A (ref 13)
 Underweight BMI <18.5 kg/m2
 Normal weight BMI 18.5- 24.9 kg/m2
 Overweight BMI 25 – 29.9 kg/m2
 Obese BMI ≥ 30 kg/m2
 Class I obesity BMI 30 – 34.8 kg/m2
 Class II obesity BMI 35 – 39.9 kg/m2
 Class III obesity BMI ≥ 40 kg/m2
o Nutritional Assessment (method based on local resources)
 Women who had bariatric surgery (B12, folic acid, iron, vitamin D and
calcium). Level B (ref 4, 5,10,20) If possible contact the patient’s
bariatric program.
o Identify co morbidities such as hypertension, sleep apnea and diabetes. (Partner
with patient’s primary care provider) Level B (ref 11, 15,18)
 Hypertension: baseline AST, creatinine, urinary protein (spot urine
protein/creatinine ratio or 24 hour urine for protein) Level C
 Sleep apnea Level B (ref 7, 12,17): STOP questions (Appendix 1)
 Cardiac function Level B (ref 16): echocardiogram and ECG for women
with edema, chest pain or decreased exercise tolerance. Consider
echocardiogram and ECG for women with multiple risk factors such as:
 Obstructive sleep apnea
 Hypertension ≥ 10 years
 Poorly controlled hypertension
 BMI ≥ 50 kg/m2
 Diabetes: consider fasting blood glucose, HbA1c, or 75 gram OGTT.
Level B (ref 13,15,18)
 Others: consider TSH, lipids, screening for nonalcoholic steatohepatitis.
Level B (ref 13,15,18)
 Discuss risks of obesity in pregnancy and recommend weight reduction. Provide patient
with obesity and pregnancy information pamphlet. Level B (ref 1,2,8)
 Consider referral to a bariatric surgery program for Class III obesity given evidence that
pregnancy outcomes may be improved by bariatric surgery. Level B (ref 5, 37)





Recommend exercise program. Encourage women that 30 minutes of sustained moderate
exercise daily is healthy and safe. Level B (ref 13,15,18)
Nutritional Consult (Patient can contact her insurance carrier to see if nutrition
consultation is a covered service.) Recommend that women eligible for WIC take
advantage of support for healthy food purchases and education. Level B (ref 13,15,18)
Multivitamin supplementation Level A (ref 9)
Folic Acid: CDC recommendation is for 400 mcg dose. Level A (ref 6) Other doses:
1mg daily. Level C The national guidelines from the United Kingdom and Canada
recommend folic acid 5 mg for 1-3 months prior to pregnancy and through the first
trimester. Level A (ref 21,22)
Recommend delay of pregnancy for women who have had bypass surgery for 12 to 18
months during phase of weight loss. Make sure the patient is aware of increased fertility
rate. Inform patients with gastric bands that it may need to be adjusted during pregnancy.
Level B (ref 14)
First Visit
 Record BMI at first visit. Level A (ref 13)
 Discuss risks of obesity. Provide patient with obesity and pregnancy information
pamphlet. Level B (ref 2,8)
 Screen for diabetes at first visit or as soon as feasible. Level B (ref 3, 32,79)
Options for screening are:
o 50 gram glucose challenge test (recommended by ACOG ref 3).
o Alternatives proposed by the American Diabetes Association: Fasting
plasma glucose ≥126 mg/dL, Hb A1c ≥ 6.5%, Random plasma glucose ≥
200 mg/dl that is subsequently confirmed by elevated fasting plasma
glucose or Hb A1C.
o See discussion of bariatric surgery patients below.
 Nutrition Counseling (based on local resources) Level B (ref 8)
 Consider consultation with maternal fetal medicine for significant co-morbidities.
Level C
 Identify co morbidities such as diabetes, hypertension, sleep apnea, cardiac
dysfunction and others. Level B (ref 15,18 )
o Hypertension: baseline AST, creatinine, 24 hour urine for protein or spot
urine protein/creatinine ratio. Level C
o Sleep apnea: STOP questions (Appendix 1) Level B (ref 12,17 )
o Cardiac function: echocardiogram and ECG for: women with chest pain,
edema or decreased exercise tolerance. Level B (ref 16) Consider
echocardiogram and ECG for women with multiple risk factors such as:
 Obstructive sleep apnea
 Hypertension ≥ 10 years
 Poorly controlled hypertension
 BMI ≥ 50 kg/m2
Considerations for bariatric surgery patient:
 Nutrient assessment: CBC, B12, folic acid, iron, vitamin D and calcium. Contact patient’s
bariatric program for guidance for other nutrient testing. (ref. 33, 34, 44)
o Administer treatment for proven deficits or contact the bariatric surgery program
for guidance for patient-specific deficits. Keep in mind that only a small
percentage of women post-bariatric surgery will continue on their prescribed
supplements. Daily recommended protein intake is 60 grams regardless of type of
surgery. Level A (ref 35)
 Women who have “dumping syndrome” cannot have a 50 gram glucose challenge test.
Alternatives include home blood glucose monitoring QID for one week during weeks 2428 of gestation. Level B (ref 36)
 Consider complications of bariatric surgery (such as band slippage or erosion, hernias,
leaks or bowel obstruction) if a patient presents with abdominal pain. Level B (ref 37, 38,
39, 43, 45)
 For patients with decreased absorptive surfaces, avoid use of extended release
medications and consider following drug levels for a medication needing a critical
therapeutic level, ie antiepileptics. Avoid nonsteroidal analgesics postpartum to avoid
gastric ulceration. Level B (ref 40, 41, 42)
Aneuploidy and congenital abnormality screening
o Must enter height and weight on lab requisition so that the lab can adjust interpretation.
Level A
o First trimester screening may be difficult. Offer serum integrated screen if a nuchal
translucency cannot be obtained. Level B (ref 23, 25, 27, 29, 30)
o If a first trimester screen is done, a second trimester MSAFP should be encouraged given
increased risk of neural tube defect. Level A (ref 23, 25, 27, 29)
o Second trimester screen as usual (offer to women entering pregnancy after 13 6/7 weeks).
Level B (ref 23, 25, 29)
o Congenital anomaly ultrasound may need to be done close to 20 weeks and obtaining all
the anatomy views may not be possible even with multiple exams. Explain that
ultrasound is not as effective at detecting congenital malformations in obese women and
that there is a greater likelihood of birth defects. Level B (24, 26, 28)
Ongoing Care
 Ultrasound exams for growth in the third trimester. Consider an ultrasound exam for
growth at 32 weeks and additional studies if the fundal height and gestational age do not
correlate. Level C
 Gestational diabetes screening: repeat at least once, usually at 24-28 weeks. Level B (ref
32, 79)
o 50 gram glucose challenge test followed, if needed, by 100 gram OGTT (ACOG
recommendation ref 3) or 75 gram OGTT (ADA recommendation ref 79).
o Consider repeat if macrosomia or polyhydramnios develops. Level C
 Follow weight gain recommendations based on BMI at first visit
o IOM recommendations for weight gain for singleton pregnancy: Level B (ref 81)
 Underweight: 28 - 40 lb
 Normal weight: 25 – 35 lb
 Overweight: 15 – 25 lb
 Obese: 11 – 20 lb
o IOM recommendations for weight gain for a twin pregnancy: Level B (ref 81)
 Underweight: no weight gain guidelines are available because of
insufficient data
 Normal weight: 37 – 54 lb
 Overweight: 31 – 50 lb
 Obese: 25 – 42 lb

Follow closely for development of preeclampsia. Level B (ref 82,83)
Pre-delivery Preparation
 Anesthesia consultation for Class III obesity (or other threshold to be set by local
hospital): Level C (ref 59, 60, 74)
o Assess impact of co-morbidities on anesthetic care, in particular sleep apnea.
o Provide input for counseling patients about intra partum anesthesia risks.
o Evaluate ability to provide emergency anesthesia (spinal or general).
o Make recommendations about preparations for delivery.
 Consider Maternal Fetal Medicine consultation for delivery if significant co- morbidities
are present to include but not limited to the following: restrictive airway, cardiac disease,
pulmonary disease. Level C
 VBAC counseling for obese patients should include the following: Level B (ref 62,63,
75,76)
o Decreased rate of success
o Increased risk of uterine rupture
o Increased time from decision for cesarean section to delivery of the baby
 Consider consultation with pediatric or NICU providers for suspected neonatal
complications. Level C
 Patient counseling to include ability to manage emergency cesarean section. Level C
Inpatient Issues (ref 48, 62-71)
 Assess availability of equipment. (ref 61)
 Appropriate sized
o Gowns
o Monitor belts
o Scales
o Blood pressure cuff
o Wheelchair
o Commode
o Sequential compression device
o Embolism prevention stockings
 Transfer help/lifts
 Labor beds/stirrup weight limit
 Step stools (to be at bedside for vaginal delivery as well as cesarean delivery)









Operating room table weight limit
Lateral table extenders
Long instruments
Long spinal needles
Admission for delivery:
o Type and screen, CBC Level C
o Secure IV access Level C
o DVT prophylaxis: sequential compression device if not out of bed Level B
(ref 49,50, 77)
o Anesthesia consultation Level C (ref 59, 60, 74)
o Consider preparations for cesarean section and consider abdominal incision
site even if labor is planned. Level C
Assess patient’s mechanics: Level C
o Ability to flex and externally rotate at thigh (avoid maternal injury particularly
with an epidural in place.)
o Labor and push on side if possible
o May need assistants for thigh retraction
Anticipate: Level A ( ref 1,2,8,15,19, 22, 52)
o Difficulty with fetal heart rate and contraction monitoring
o Difficulty with IV access. Consider IV access for all patients.
o Difficult placement of epidural, inadequate function. Consider placement
early.
o Higher rate of shoulder dystocia (suprapubic pressure will need to be done
under the pannus)
o Dysfunctional labor
o More unscheduled cesarean sections
o Postpartum hemorrhage
 Oxytocin use for active management of the third stage of labor should
be considered for women with a BMI ≥ 30 kg/m2 as they are at
increased risk of PPH. Level A (ref 52, 53)
o Longer operating room time
o Decreased ability to handle emergency cesarean section
o More intrapartum and postpartum infection: avoid multiple exams and early
AROM, treat hyperglycemia.
Frequent vital signs: Level C
o Include intake/output tally
o Consider pulse oximetry with vital signs
Safety huddle/team meeting on admission, repeat if change of personnel: Level C
o Assure all team members are available
o Equipment check list
o Identify individual roles for emergency cesarean section, shoulder dystocia,
hemorrhage

Delivery Plans for Cesarean Section:
o Operating room table extenders and long instruments available Level C(ref 61)
o As needed, pre-operative shower with antiseptic soap Level C
o Pre-operative antibiotics even if elective surgery Level A (ref 46)
o Consider self-retaining flexible retractors (Alexis® or Mobius®) based on
patient- specific anatomy. Level C
o Sequential compression device prior to prep and drape Level A (ref 1, 77)
o Consider obtaining additional operative assistants. Level C
o Close subcutaneous space with absorbable suture Level A (ref 47)
o Avoid use of drains and consider transverse abdominal incision in women with a
BMI ≥35 kg/m2. Level B (ref 48, 78)
Postpartum care
 Early ambulation after delivery Level A (ref 49)
 DVT prophylaxis Level B (ref 49, 50, 84, 85, 86)
o Vaginal delivery and cesarean delivery: Sequential compression devices until
ambulatory without assistance.
o Cesarean delivery patients with additional risk factors, initiate Lovenox 40 mg sc
daily starting 12 hours after delivery until discharge.
 Risk factors: unscheduled cesarean section, infection (e.g.
chorioamnionitis and endometritis), EBL ≥ 1000 cc, multiple gestation,
smoking > ½ ppd, IUGR, preeclampsia, thrombophilia, blood transfusion,
strict bed rest for at least one week in the antepartum period, previous
DVT/PE and medical conditions (SLE, heart disease and sickle cell
disease).
 If an epidural catheter is used, consult with the anesthesiologist regarding
pharmacologic thromboprophylaxis.
 Incentive spirometer Level C (ref 51)
 Assure that patient completely changes position in bed every 2 hours. Level C (ref 51)
 For patient with diabetes after cesarean delivery, maintain glucose control: Level C (ref
32)
o fasting glucose goals of <126 mg/dL
o random glucose readings <200 mg/dl
 Consider lactation consultant. Level A (ref 54-58)
Postpartum office care:
o Repeat glucose challenge test if gestational diabetes (A1 or A2). Level B (ref 31, 32)
o Continue nutrition support. Level B (ref. 13, 15,18)
o Encourage weight loss. Level B (ref. 13, 15,18)
o Provide specific recommendations including local resources.
o Explain that interpregnancy weight gain increases the risk of pregnancy
complications and interpregnancy weight loss decreases the risk of gestational
diabetes. Level B (ref 72, 73)
o Encourage engagement in primary care. Level C
Contraception:
 US Medical Eligibility Criteria for Contraceptive use 2010: Level A (ref 80)
 1 = A condition for which there is no restriction for the use of the
contraceptive method.
 2 = A condition for which the advantages of using the method generally
outweigh the theoretical or proven risks.
 3 = A condition for which the theoretical or proven risks usually outweigh
the advantages of using the method.
 4 = A condition that represents an unacceptable health risk if the
contraceptive method is used.
o History of bariatric surgery who are now normal weight
 Restrictive surgical procedures
 Category 1: all methods other than restrictions noted below
 Category 2:
o POP, DMPA, implants < 30 days postpartum
o COC/patch/ring if breastfeeding > 30 days postpartum
 Category 3: COC/patch/ring if breastfeeding 21-30 days
postpartum (Category 4 if additional risk factors)
 Category 4: COC/patch/ring if breastfeeding < 21 days postpartum
 Malabsorptive surgical procedures
 Category 1: Depoprovera® (DMPA), Patch, Ring, implants,
IUD’s, emergency contraceptive, barrier
 Category 3: Combination oral contraceptive (COC), progesterone
only oral contraceptive (decreased effectiveness) (Category 4 until
42 days if additional risk factors)
 Category 4: COC/patch/ring if breast feeding < 21 days
postpartum
o Obesity
 Category 1
 Progesterone only oral contraceptive, DMPA, implants (POP)
unless breast feeding < 30 days postpartum
 Emergency oral contraception regimen
 IUDs
 Barrier methods
 Category 2
 COC/patch/ring (> 42 days postpartum)
 DMPA (menarche to 18 yrs) due to wt gain
 POP (if breastfeeding < 30 days postpartum)
 Category 3
 COC/patch/ring (21-42 days postpartum) (Category 4 until 42
days if additional risk factors)
 All oral contraceptives after malabsorptive bariatric surgery
 Category 4
 COC/patch/ring (<21 days postpartum)
o Specific comments regarding obesity
 Combined oral contraceptives: Obese women who used COCs were at
increased risk of venous thromboembolism compared with non-users. The
absolute risk of venous thromboembolism remained small. Data are
limited regarding the impact of obesity on COC effectiveness.
 Patch: Limited evidence suggests the effectiveness of the patch may
decline for women weighing 90kg or more
 Depoprovera®: Studies provide conflicting evidence regarding whether
obese women are at increased risk of weight gain and bleeding problems
relative to non-obese women using DMPA.
 Sterilization: The procedure may be more difficult. There is an increased
risk of wound infection and disruption. Obese women may have limited
respiratory function and may be more likely to require general anesthesia.
Delay Essure placement for 6-12 weeks postpartum.
Proposed Performance Measure:
The percentage of pregnant patients with BMI ≥ 30 kg/m2 for whom diabetes screening is
performed in the first trimester or at the onset of pregnancy care.
Appendix:
1. STOP Questionnaire screen for sleep apnea
2. Criteria for evaluation of level of evidence, USPSTF
3. Patient Information Handout: Obesity and Pregnancy
Appendix 1: STOP Questionnaire (ref 7)
1. Snoring
Do you snore loudly (louder than talking or loud enough to be heard through closed doors)?
Yes No
2. Tired
Do you often feel tired, fatigued, or sleepy during daytime?
Yes No
3. Observed
Has anyone observed you stop breathing during your sleep?
Yes No
4. Blood pressure
Do you have or are you being treated for high blood pressure?
Yes No
High risk of OSA: answering yes to two or more questions
Low risk of OSA: answering yes to less than two questions
Appendix 2
Studies were reviewed and evaluated for quality according to the method outlined by the
U.S. Preventative Services Task Force
I Evidence obtained from at least one properly designed randomized controlled trial.
II–1 Evidence obtained from well–designed controlled trials without randomization.
II–2 Evidence obtained from well–designed cohort or case–control analytic studies, preferably
from more than one center or research group.
II–3 Evidence obtained from multiple time series with or without the intervention. Dramatic
results in uncontrolled experiments also could be regarded as this type of evidence.
III Opinions of respected authorities, based on clinical experience, descriptive studies, or reports
of expert committees.
Based on the highest level of evidence found in the data, recommendations are provided and
graded according to the following categories:
Level A—Recommendations are based on good and consistent scientific evidence.
Level B—Recommendations are based on limited or inconsistent scientific evidence.
Level C—Recommendations are based primarily on consensus and expert opinion.
References:
1. ACOG Committee Opinion 315 September 2005 Obesity in pregnancy
2. ACOG Committee Opinion 319 October 2005 The Role of the Obstetrician-Gynecologist in
the Assessment and Management of Obesity
3. ACOG Practice Bulletin 30 Gestational Diabetes September 2001 (reaffirmed 2008)
4. ACOG Practice Bulletin 105 June 2009 Bariatric Surgery and Pregnancy
5. Buchwald H. Consensus conference statement. Bariatric surgery for morbid obesity: health
implications for patients, health professionals, and third party payers. J Am Coll Surg 2005;
200:593–604
6. Centers for Disease Control. Recommendations for the use of folic acid to reduce the number
of cases of spina bifida and other neural tube defects. MMWR 1992; 41 (No. RR-14): (inclusive
page numbers)
7. Chung F. STOP Questionnaire A tool to screen patients for obstructive sleep apnea
Anesthesiology 2008; 108:812–21
8. Davies GA. Obesity in Pregnancy Clinical Practice Guideline. Journal of obstetrics and
gynaecology. 2010 vol. 32(2) 165-173
9. Gardiner PM The clinical content of preconception care: nutrition and dietary supplements.
Supplement to December 2008 American Journal of Obstetrics & Gynecology S345
10. Koch TR, et al Postoperative metabolic and nutritional complications of bariatric surgery
Gastroenterology Clinics – 2010 Volume 39, Issue 1
11. Lee et al. Maternal obesity: Effects on pregnancy and the role of pre-conception counseling.
Journal of obstetrics and gynaecology. February 2010; 30(2) 101-106
12. Louis JM, et al. Maternal and neonatal morbidities associated with obstructive sleep apnea
complicating pregnancy. Am J Obstet Gynecol 2010; 202:261.e1-5.
13. McTigue, et al. Screening and interventions for obesity in adults: summary of the evidence
for the U.S. Preventive Services Task Force. Ann Intern Med 2003 Dec 2;139(11):933-49.
14. Mechanick, J et al. American Association of Clinical Endocrinologists, the Obesity Society
and American Society for Metabolic and Bariatric Surgery, Medical Guidelines for Clinical
Practice for the perioperative, nutritional, metabolic, and nonsurgical support o the bariatric
surgery patient. Surgery for Obesity and Related Diseases 2008 (4) S109-S184
15. National Collaborating Centre for Primary Care. Obesity: the prevention, identification,
assessment and management of overweight and obesity in adults and children. London (UK):
National Institute for Health and Clinical Excellence 2006 Dec. 2590 http www.nice.org.uk
16. Patel MR, et al. ACCF proposed method for evaluating the appropriateness of cardiovascular
imaging. J Am Coll Cardiol 2005; 46:1606-13 (1).
17. Sahin,et al.Obstructive sleep apnea in pregnancy and fetal outcome. International Journal of
Gynecology and Obstetrics (2008) 100, 141–146
18. Snow V, et al. Pharmacologic and surgical management of obesity in primary care: a clinical
practice guideline from the American College of Physicians. Ann Intern Med 2005 Apr 5;
142(7):525-31.
19. Yogeev et al. Pregnancy and obesity Obstet Gynecol Clin N Am 36 (2009) 285–300
20. Ziegler O et al. Diabetes & Metabolism 35 (2009) 544-557 Medical follow up after bariatric
surgery: nutritional and drug issues General recommendations for the prevention and treatment
of nutritional deficiencies Diabetes & Metabolism 35 (2009) 544–557
21. Wilson R et al. Genetics Committee of the Society of Obstetricians and Gynaecologists of
Canada. Pre-conceptional vitamin/folic acid supplementation 2007: the use of folic acid in
combination with a multivitamin supplement for the prevention of neural tube defects and other
congenital anomalies. J Obstet Gynaecol Can 2007 Dec; 29(12):1003-13.
22. Modder J, CMACE and Fitzsimons K. Centre for Maternal and Child Enquiries and the
Royal College of Obstetricians and Gynaecologists. Management of pregnancy in women with
obesity March 2010.
23. American College of Obstetricians and Gynecologists. Screening for fetal chromosomal
abnormalities. Practice Bulletin 77. January, 2007 (reaffirmed 2008)
24. Dashe JS et al Effect of maternal obesity on the ultrasound detection of anomalous fetuses.
Obstet Gynecot. 2009;13:1001- 1007
25. Malone FD, Wald NJ, Canick JA, Ball RH, Nyberg DA, Comstock CH, et al. First- and
second-trimester evaluation of risk (FASTER) trial: principal results of the NICHD multicenter
Down syndrome screening study [abstract]. Am J Obstet Gynecol 2003;189:(suppl 1):s56.
26. Paladini D. Sonography in obese and overweight pregnant women: clinical, medicolegal and
technical issues Ultrasound Obstet Gynecol 2009; 33: 720–729
27. Spencer K, Spencer CE, Power M, Dawson C, Nicolaides KH. Screening for chromosomal
abnormalities in the first trimester using ultrasound and maternal serum biochemistry in a onestop clinic: a review of three years prospective experience. BJOG 2003;110:281–6.
28. Stothard, KJ et al. Maternal overweight and obesity and the risk of congenital anomalies. A
systematic review and meta-analysis JAMA. 2009;301(6):636-650
29. Wald NJ, Rodeck C, Hackshaw AK, Walters J, Chitty L, Mackinson AM. First and second
trimester antenatal screening for Down's syndrome: the results of the Serum, Urine and
Ultrasound Screening Study (SURUSS) [published erratum appears in J Med Screen
2006;13:51–2]. J Med Screen 2003;10:56–104.
30. Wapner RJ, Thom EA, Simpson JL, Pergament E, Silver R, Filkins K, et al. First-trimester
screening for trisomies 21 and 18. First Trimester Maternal Serum Biochemistry and Fetal
Nuchal Translucency Screening (BUN) Study Group. N Engl J Med 2003;349:1405–13.
31. ACOG Committee Opinion 435 June 2009 Postpartum screening for abnormal glucose
tolerance in women who had gestational diabetes mellitus
32. American Diabetes Association. Standards of medical care in diabetes – 2008. Diabetes
Care 2008;31 suppl 1)
33. Willgrove AC, Pregnancy following gastric bypass for morbid obesity. Obes. Surg 1998:8:
461-4 (level III)
34. Poitou Bernet C, Nutritional deficiency after gastric bypass: diagnosis, prevention and
treatment Dibetes Metab 2007:33:13-24 (level III)
35. Kramer MS Energy and protein intake in pregnancy Cochrane Database of Systematic
Reviews 2003, Issue4. Art. No. CD000032. DOI: 10.1002/146518.CD000032 (meta-analysis)
36. American Diabetes Association, Gestational diabetes mellitus, Practice Guidelines. Diabetes
Care. 27 Suppl 1:588-90, 2004 Jan (level III)
37. Maggard M Pregnancy and Fertility Following Bariatric Surgery: A Systematic Review
JAMA 2008;300(19): 2286-2296.
38. Patel JA Pregnancy outcomes after laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat
Dis 2008 4(1):39-45 (level?)
39. Skull, AJ Laparoscopic adjustable banding in pregnancy: safety, patient tolerance, and effect
on obesity-related pregnancy outcomes Obes Surg 2004; 14(2):230-235
40. Edmiston CE et al Perioperative antibiotic prophylaxis in the gastric bypass patient: do we
achieve therapeutic levels? Surgery 2004; 136:738-47 (level II-3)
41. Prince RA Influence of bariatric surgery on erythromycin absorption J Clin Pharmacol
1984;24:523-7 (level III)
42. Miller AD Medication and nutrient administration considerations after bariatric surgery. Am
J Health Syst Pharm 2006;63:1852-7 (level III)
43 Ducarme, et al.Obstetric outcome following laparoscopic adjustable gastric banding.
International Journal of Gynecology and Obstetrics (2007) 98, 244–247
44. Faintuch J. Pregnancy nutritional indices and birth weight after Roux-en-Y gastric bypass
Obes Surg (2009) 19:583–589
45. Sheiner E. Pregnancy outcome in patients following different types of bariatric surgeries
Obes Surg (2009) 19:1286–1292
46. Small F, Gyte GML. Antibiotic prophylaxis for cesarean section. Cochrane Database
Systematic Reviews 2010; 1; CDOO7482
47. Chelmow D, et al. Suture closure of subcutaneous fat and wound disruption after cesarean
delivery; a meta-analysis. Obstetrics and Gynecology 2004; 103: 974-80.
48. Alanis MC et al. Complications of cesarean delivery in the massively obese parturient.
American Journal of Obstetrics and Gynecology. 2010 Sep; 203 (3): 271.e1-7
49. Jacobsen AF et al.. Ante- and postnatal risk factors of venous thrombosis: a hospital based
case control study. Journal of Thrombosis and Haemostasis 2008;6(6):905-912. Level A II-2
50. James AH et al. Venous thromboembolism during pregnancy and the postpartum period:
Incidence, risk factors, and mortality. American Journal of Obstetrics and Gynecology. 2006:
194, 1311-5
51. Wong DL, Hockenberry MJ, Perry SE, & Lowdermilk DL. Maternal Child Nursing Care.
(2006) Mosby
52. Sebire NJ et al. Maternal obesity and pregnancy outcome: a study of 287,213 pregnancies in
London. International Journal of Obesity & Related Metabolic Disorders: Journal of the
International Association for the Study of Obesity 2001;25(8):1175-82.
53. Prendiville WJ et al.. Active versus expectant management in the third stage of
labour.[update of Cochrane Database Syst Rev. 2000;(2):CD000007]. Cochrane Database of
Systematic Reviews 2000(3). Level A I
54. Amir LH, Donath S. A systematic review of maternal obesity and breastfeeding intention,
initiation and duration. MC Pregnancy and Childbirth 2007;7:9.
55. Mok E et al. Decreased full breastfeeding, altered practices, perceptions, and infant weight
change of prepregnant obese women: A need for extra support. Pediatrics 2008;121(5):e13191324.
56. Rasmussen KM, Kjolhede CL. Prepregnant overweight and obesity diminish the prolactin
response to suckling in the first week postpartum. Pediatrics 2004;113(5):e465-71.
57. Dyson L et al. Interventions for promoting the initiation of breastfeeding. Cochrane
Database of Systematic Reviews 2005(2):CD001688.
58. Fairbank L, O'Meara S, Renfrew MJ, Woolridge M, Sowden AJ, Lister-Sharp D. A
systematic review to evaluate the effectiveness of interventions to promote the initiation of
breastfeeding. Health Technology Assessment, 2000;4(25). Level A- I
59. Roofthooft E. Anesthesia for the morbidly obese parturient. Current Opinion in
Anesthesiology, 2009 Jun; 22 (3): 341-6
60. Sinha AC Some anesthetic aspects of morbid obesity. Current Opinion in Anesthesiology,
2009 Jun; 22 (3): 442-446
61. Akridge J. Operating room. Super-sized equipment supports bariatric needs. Purchasing
News, 2008 Jan; 32 (1): 20, 22, 24
62. Durnwald CP et al. The impact of maternal obesity and weight gain on vaginal birth after
cesarean section success. American Journal of Obstetrics & Gynecology, 2004 Sep; 191 (3):
954-7
63. Edwards RK et al. Deciding on route of delivery for obese women with a prior cesarean
delivery. American Journal of Obstetrics & Gynecology, 2003 Aug; 189 (2): 385-90
64 Morin KH et al. Caring for obese pregnant women. Journal of Obstetric, Gynecologic &
Neonatal Nursing, 2007 Sep-Oct; 36 (5): 482-9
65. Verdiales M et al. The effect of maternal obesity on the course of labor. Journal of
Perinatal Medicine, 2009; 37 (6): 651-5
66. Veerareddy S et al. Obesity: implications for labour and puerperium. British Journal of
Midwifery, 2009 Jun; 17 (6): 360-2
67. Ehrenberg HM et al. Maternal obesity, uterine activity, and the risk of spontaneous preterm
birth. Eunice Kennedy Shriver National Institute of Child Health and Human Development
(NICHD) Maternal-Fetal Medicine Units Network (MFMU); Obstetrics & Gynecology, 2009
Jan; 113 (1): 48-52
68. Obesity and spontaneous labor at term. ACOG Clinical Review, 2008 Nov-Dec; 13 (6): 2-3
69. Magriples U et al. The effects of obesity and weight gain in young women on obstetric
outcomes. American Journal of Perinatology, 2009 May; 26 (5): 365-71
70. Rajasingam D et al. A prospective study of pregnancy outcome and biomarkers of oxidative
stress in nulliparous obese women. American Journal of Obstetrics & Gynecology, 2009 Apr;
200 (4): 395.e1-9
71. James DC et al. Caring for the extremely obese woman during pregnancy and birth. MCN:
The American Journal of Maternal Child Nursing, 2009 Jan-Feb; 34 (1): 24-30
72. Villamor E, et al, Interpregnancy weight change and risk of adverse pregnancy outcomes: a
population-based study. The Lancet 2006;368(9542):1164-1170.
73. Glazer NL, et al. Weight change and the risk of gestational diabetes in obese women.
Epidemiology 2004;15(6):733-737.
74. Vallejo MC. Anesthetic management of the morbidly obese parturient. Curr Opin
Anaesthesiol 20:175–180.
75. Hibbard JU et al. Trial of labor or repeat cesarean delivery in women with morbid obesity
and prior cesarean delivery. Obstet Gynecol. 2006;108(1):125-33.
76. Juhasz G et al. Effect of body mass index and excessive weight gain on success of vaginal
birth after cesarean delivery. Obstet Gynecol 2005;106(4):741-6
77. ACOG Practice Bulletin 84 Prevention of deep venous thrombosis and pulmonary embolism
August 2007
78. Wall P et al. Vertical skin incisions and wound complications in the obese parturient
Obstet Gynecol 2003;102:952– 6.
79. International Association of Diabetes and Pregnancy Study Groups Consensus Panel.
International association of diabetes and pregnancy study groups recommendations on the
diagnosis and classification or hyperglycemia in pregnancy. Diabetes Care 33(3) 676-682.
80. Centers for Disease Control and Prevention . U.S. medical eligibility criteria for
contraceptive use, 2010. MMWR Early Release 2010;59 May 28, 2010:[1-86].
And
Update to the CDC’s U.S. medical eligibility criteria for contraceptive use, 2010; Revised
recommendations for use of contraceptive methods during the postpartum period. MMWR 2011;
60 (26): 878-883.
81. Kathleen M. Rasmussen and Ann L. Yaktine, Editors. Committee to Reexamine IOM
Pregnancy Weight Guidelines; Institute of Medicine; National Research Council Weight gain
during pregnancy. The National Academies Press, 2009
82. Cedergren MI. Maternal morbid obesity and the risk of adverse pregnancy outcome.
Obstetrics and Gynecology 2004;103(2):219-24.
83. O'Brien TE, Ray JG, Chan W-S. Maternal body mass index and the risk of preeclampsia: a
systematic overview. Epidemiology 2003;14(3):368-74.
84. Horlocker TT, et al. Regional Anesthesia in the Patient Receiving Antithrombotic or
Thrombolytic Therapy: American Society of Regional Anesthesia and Pain Medicine EvidenceBased Guidelines (Third Edition) Regional Anesthesia & Pain Medicine:
January/February 2010 - Volume 35 - Issue 1 - pp 64-101
85. Bates SM, et al. VTE, Thrombophilia, Antithrombotic Therapy and Pregnancy:
Antithrombotic therapy and prevention of thrombosis, 9th edition. American College of Chest
Physicians Evidence- Based Clinical Practice Guidelines. Chest 2012; 141(2)(suppl):e691S-e736S.
86. Varner, MW. Thromboprophylaxis for cesarean delivery. Contemporary OB/GYN 2011;
56(6): 30-33.