MATERNITY SERVICES GUIDELINE
OBESITY
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Date of first issue
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Version information
Obesity Guideline Version 3 February 2012
Louvain Shaw Midwife, Helen Joyce Midwife.
October 2009
3
February 2012
Obs & Gynae Clinical Governance Forum
10th February 2012
February 2015
Updated in line with clinical practice
Page 1 of 12
Contents
Section
Page
1. Guideline Flow chart
3
2. Introduction & Definitions
3
3. Management
4
4. Antenatal
5
5. Intrapartum
5
6. Anaesthetic risks associated with obesity
6
7. Postnatal
7
8. Monitoring Compliance with the guideline
8
9. Links with
8
10. References
8
Appendix 1 Equipment available
9
Appendix 2 Guideline for use of equipment for overweight patients
10
Appendix 3 Monitoring Compliancy
11
Obesity Guideline Version 3 February 2012
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1. Guideline Flowchart
(refer to full guideline for further information)
Booking appointment: All pregnant women must have an accurate measurement of
height and weight taken (preferably, before 12 weeks) and BMI calculated.
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Women with a BMI ≥ 30 and above:
Should be given the patient information leaflet on obesity (raised BMI and
lifestyle changes)
Vitamin D 10mcg/day supplement ( prescribed by GP)
Glucose Tolerance Test, arranged through Antenatal clinic at their 20 wk scan
appointment.
All women with a BMI ≥ 30 consider presentation USS on admission for
labouring women and before IOL.
They also need to be re- weighed again at 36 weeks.
All women with a BMI≥30 should be recommended to have active
management of the third stage of labour.
Women with a BMI ≥ 35
Women with a BMI ≥ 35 must be booked consultant care and should have
antenatal consultation with an obstetric consultant to discuss possible
intrapartum complications, the discussion must be documented in the health
record.
These women are not suitable for midwifery led care and should be advised to
deliver in hospital
Women with BMI ≥40
Women with BMI ≥40 at booking should be referred to the Lead Obstetric
Anaesthetist irrespective of the planned mode of delivery. This is done by the
consultant unit team at 20 wks scan appointment.
The duty anaesthetist should also be aware of all women with a BMI ≥40
admitted to the maternity unit. The duty anaesthetist should be notified
immediately of all women with a BMI ≥ 40 who are admitted in labour.
All women in labour with a BMI ≥ 40 and above must have a grey cannula (16
gauge) sited together with a FBC and group and save sent to lab.
In women with a BMI ≥ 40, a fetal scalp electrode should be applied to record
the fetal heart rate if unable to obtain a good external CTG trace.
BMI of 40 and above, regardless of their mode of delivery require Fragmin for
7 days. Patients at particularly high risk may need a 6- 8 week course of
Fragmin.
Obesity Guideline Version 3 February 2012
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2. Introduction & definition
Obesity is defined by the World Health Organisation (WHO) (1998) and the National
Institutes of Health (1998) as a Body Mass Index (BMI) of ≥30.
Body Mass Index (BMI) is an index of weight-for-height. It is calculated by the
weight in kilograms divided by the square of the height in metres (kg/m2)
The prevalence of obesity in pregnancy is on the rise and it is becoming increasingly
more urgent to have guidelines and strategies in place to be able to give care to this
group of women.
The role of this guideline is to outline the appropriate management strategies to
minimise the clinical risk to this group of women.
In the last CEMACH (2007) report obesity alone was identified as a risk factor for
maternal death, following the finding that 35% of all mothers who died were obese. It
was recommended that women with a BMI ≥ 35 at first contact are unsuited for
midwife led care and that they should deliver in a consultant unit with appropriate
emergency facilities.
In order to make the pregnancy safer for obese women it should be acknowledged
that they represent a “high risk pregnancy”
1. Management
Pregnancy risks associated with obesity:
Obesity is a recognised risk factor for a range of antenatal, intrapartum and postnatal
complications with maternal BMI ≥ 30 being a recognised risk factor for:
 Hypertension and pre-eclampsia
 Gestational diabetes
 Difficulty with physical examinations
 Thromboembolic disease
 Fetal macrosomia
 Difficulty in monitoring fetal heart rate
 Prolonged labour
 Increased rate of LSCS
 Difficult operative procedures
 Risks associated with anaesthesia
 Wound infections
 Shoulder dystocia
 Maternal Death
 Failure to progress in labour
4. Antenatal:
1. All pregnant women must have an accurate measurement of height and
weight taken at their booking visit (preferably, before 12 weeks) and BMI
Obesity Guideline Version 3 February 2012
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calculated. They also need to be re- weighed again at 36 weeks. This should
be carried out by a healthcare professional using appropriate equipment.
These measurements must be clearly documented in the women’s hand held
notes and electronic patient information system. Self reported weights and
height should not be used as substitutes.
2. Blood pressure readings must be recorded using an appropriately sized cuff.
3. Women with a BMI ≥ 30 and above should be given the patient information
leaflet on ‘Raised BMI and Lifestyle Changes’ Women should be given the
opportunity to discuss this information.
4. Women with BMI ≥30 at booking should have a Glucose Tolerance Test
(GTT), arranged through Antenatal clinic at their 20 wk scan appointment. At
the GTT appointment consideration will be given regarding midwifery led care
or consultant led care. Women with a BMI ≥30 at booking are not currently
booked for Consultant led care due to resources.
5. Women with a BMI ≥ 35 must be referred to a consultant obstetrician for
Consultant led care. These women are not suitable for midwifery led care and
should be advised to deliver in hospital with appropriate neonatal services.
6. Risks of pregnancy complications and morbidity should be discussed and
recorded in the woman’s notes. Women with a BMI ≥ 35 must be booked
consultant care and should have antenatal consultation with an obstetric
consultant to discuss possible intrapartum complications, the discussion must
be documented in the health record.
7. Women with BMI ≥40 at booking should be referred to the Lead Obstetric
Anaesthetist irrespective of the planned mode of delivery, so that potential
difficulties with venous access, regional or general anaesthesia can be
identified. This is done by consultant unit team at 20 wks scan appointment or
at subsequent appointment when a letter is sent to request the mother for an
anaesthetic review. An individualised management plan should be written in
the woman’s maternity notes and any specialised equipment identified. Dietary
advice should be given and referral to dietician offered.
8. Venous thromboembolism Risk Assessment form to be completed at booking
and on each admission to hospital.
5. Intrapartum:
1. All women with a BMI ≥ 30 consider presentation USS on admission for
labouring women and before IOL.
2. All women in labour with a BMI ≥ 40 and above must have a grey cannula (16
gauge) sited together with a FBC and Group and Save sent to lab.
3. Administer oral Ranitidine 150 mg / 6 hourly, in labour. Consumption of food
should be avoided, clear fluids only.
Obesity Guideline Version 3 February 2012
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4. In women with a BMI ≥ 40, a fetal scalp electrode should be applied to record
the fetal heart rate if unable to obtain a good external CTG trace.
5. All women with a BMI≥30 should be recommended to have active
management of the third stage of labour.
6. All staff must follow the Trust Manual Handling policy, consider transferring
and positioning.
7. A manual handling risk assessment on admission must be completed and
reassess throughout labour and recorded 2 hourly in the maternity in patient
notes.
8. Suitable equipment such as large BP cuffs are available in all care settings
including the community. Large chairs, wheelchairs are available throughout
the Trust for further information refer to Bariatric Guidelines in the Manual
Handling Resource Pack or contact one of the Manual Handling Link
Midwives. Also see (Appendix 1) Maximum Load Weight of Equipment and
(Appendix 2) Guideline for use of equipment for overweight patients. This
equipment will be assessed annually by the Manual Handling Link Midwives.
6. Anaesthetic risks associated with obesity:
Practical:
Transferring and Positioning
Practical procedures such as IV access, regional
anaesthesia, intubation, mask ventilation
Special equipment needed such as stronger beds
and tables
Monitoring
Associated conditions:
Diabetes
Sleep apnoea
Hypertension
Gastro-oesophageal Reflux
The duty anaesthetist should also be aware of all women with a BMI ≥40 admitted to
the maternity unit, as they may have additional risks and potential difficulties.
The duty anaesthetist should be notified immediately of all women with a BMI ≥ 40
who are admitted in labour. A consultant anaesthetist (Specialty Trainee year 6 and
above) should be informed and available for the care of women with a BMI ≥40
during labour and delivery, including attending any operative vaginal or abdominal
delivery advising what analgesia or anaesthetic should be used.
If a delivery plan is available the duty anaesthetist should follow it. If it is not they
should assess the woman paying particular attention to:
Airway assessment
Any history or suspicion of obstructive sleep apnoea
Any coexisting disease
Obesity Guideline Version 3 February 2012
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A multidisciplinary delivery plan should be formed considering the obstetric risk in
light of high BMI and any additional anaesthetic concerns.
Extra care should be taken to avoid lying a women flat as aorta compression is
exacerbated. This must never be under estimated.
The high risks of a general anaesthetic in this group coupled with the likelihood of
difficulty with regional anaesthesia mean that siting an epidural early in labour, when
there is no urgency and calling of a 2nd anaesthetist if necessary, seems the prudent
and safest choice. This should be explained to the woman, who should have had this
discussed antenatally. Once an epidural is sited the anaesthetist must ensure it is
working well and continues to work well in case it needs to be topped for a theatre
procedure later.
If theatre is needed a general anaesthetic should be avoided if at all possible. A
senior anaesthetist should be involved. Extra monitoring may be required (e.g.
arterial line as non-invasive cuffs tend to misread) and HDU care may well be
needed post operatively. Good analgesia is essential but opiates will exacerbate
sleep apnoea and reduce mobility postoperatively. Other points for consideration
Sitting up for pre-oxygenation and intubation
Ensuring adequate suxamethonium is given
Inducing and siting regional anaesthesia in theatre so that she doesn’t
have to be moved on the table
Sitting her up before extubation
Getting extra people into theatre to help with positioning
7. Postnatal:
1. Early mobilisation
2. Particular risks are concealed PPH, Obstructive Sleep Apnoea difficulties
measuring BP, DVT, slow mobilisation and wound infection
3. Consider use of HDU facilities post delivery due to risks of respiratory and
cardiovascular complications.
4. Refer to physiotherapists, as indicated.
5. Postnatal VTE risk assessment completed and appropriate Fragmin should be
prescribed doses appropriate for maternal weight. Refer to thrombo
prophylaxis guideline.
6. BMI of 40 and above, regardless of their mode of delivery require Fragmin for
7 days. Women at particularly high risk may need a 6- 8 week course of
Fragmin.
7. Dietary advice should be given and referral to dietician offered.
8. It is also recommend for future pregnancies that women receive prepregnancy counselling and folic acid supplementation.
Obesity Guideline Version 3 February 2012
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8. Monitoring Compliance: See Appendix 1
This will be monitored as part of the Annual Audit Programme.
The lead person will be responsible for completion of the monitoring process by
means of an audit, development of an action plan, any subsequent actions and their
dissemination.
Process
for
monitoring
e.g. audit
Audit
Lead
Responsible
Naomi Inman
Frequency
of
monitoring
Responsible Lead /
Committee for review of
results and development
of action plan
Annually –
according
to Annual
Audit plan
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
Obs & Gynae Clinical
Governance Forum
Labour Ward Forum &
Obstetric Risk Group
Responsible Lead /
Committee for
monitoring
of action plan

Obs & Gynae
Clinical Governance
Forum
9. Links with:
Bariatric Guidelines in the Manual Handling Resource Pack
Pregnancy and Obesity Patient Information Leaflet
Home Birth guideline
Thrombo-prophylaxis guideline
Antenatal Day Services guideline
10. References:
M Dresner, J Broklesby, J Bamber: Audit of the influence of BMI on the performance
of epidural analgesia in labour and the subsequent mode of delivery. BJOG. Vol113.
Issue10.
ROCOG (2010) Joint Guideline: Management of Women with Obesity in Pregnancy
London
Centre for Maternal and Child Enquiries (CMACE). Maternal obesity in the UK:
Findings from a national project. London: CMACE, 2010.
U Krishnamoorthy, CMH Schram, Sr Hill: Maternal obesity in pregnancy: is it time for
meaningful research to inform preventive and management strategies? BJOG. Vol
113 Issue 10.
Lewis, G (Ed) 2007: The Confidential Enquiry into Maternal and Child Health
(CEMACH). ‘Saving Mothers’ Lives: Reviewing Maternal Deaths to Make Motherhood
Safer-2003-2005’. The Seventh Report on Confidential Enquiries into Maternal
Deaths in the United Kingdom. London: CEMACH.
National Institute for Health and Clinical Excellence (NICE) 2008: Clinical guideline
62: Antenatal care: Routine care for the healthy pregnant woman. London
Richens Y,(2008) Tackling maternal obesity: Suggestions for midwives. British
Journal of Midwifery: vol16: 1p 14-18.
CKH Yu, TG Teoh, S Robinson: Obesity in pregnancy. BJOG Vol113, issue 10.
Obesity Guideline Version 3 February 2012
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Appendix 1 Equipment available
Ward Area
Ward G2/G3
Labour Ward
Equipment available
Kings Fund Bed
Huntleigh Profile Bed-Centura
Huntleigh Profile Bed 480
Wide Bedside Chair
Hill Rom Affinity Delivery Bed
Theatre table- Room 15
Maximum Weight
180 kgs
250 kgs
267 kgs
225 kgs
227 kgs
225 kgs table not to be
moved > 135 kgs
225 kgs table not to be
moved > 135 kgs
225 kgs
160 kgs
180 kgs
225 kgs
180 kgs
180 kgs
225 kgs
180 kgs
180 kgs
225 kgs
Theatre table- Operating Theatre
Antenatal Clinic
Antenatal Day Unit
Triage Unit
All Areas
Wide Bedside Chair
Parker Knoll Recliner Chair
Theatre Trolley
Wide Waiting Room Chairs
Examination Couch
Kings Fund Bed
Wide Waiting Room Chair
Examination Couch
Kings Fund Bed
Wide Waiting Room Chair
Wheelchair – Bradfern X-ray Wheelchair
Heavy duty wheelchairs available from
main porters
134 kgs
Maximum Load Weight of Equipment
See Manual Handling Bariatric Flowchart for Trust equipment availability
Further information available from the Manual Handling Resource Folder
Obesity Guideline Version 3 February 2012
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Appendix 2
GUIDELINES FOR USE OF EQUIPMENT FOR OVERWEIGHT PATIENTS
<114kg (18st)
114kg – 180kg (18-28st)
>180kg (28st)
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Standard equipment may be used
Profiling bed or
prima pink foam mattress (on some ward beds)
(kings fund bed may be used)
Heavy-weight Profiling bed (up to 267kg)
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Heavy duty chair (on G2)
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Heavy duty chair (on G2)
Arrange with porter for a heavy- duty
wheelchair if required. Wheelchair may be
available from OT
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Arrange with porter for a heavy-duty wheelchair if
required
Wheelchair may be available from OT
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Equipment co-ordinator available on Bleep
300 for access to Trust heavy duty equipment
 Remember weight now, not booking weight.
 36/40 weight may need checking on admission if close to the upper weight limit.
 Scales on G3 weigh up to 190kg, may use 2 scales if required.
 Scales on G1 weigh up to 200kg
 Liko Gantry scales weigh up to 317kg – phone works (ext 5566) will need requisition.
 Refer to guidelines for very heavy patients/bariatric patients.
 Refer to pool guidelines re: exclusion criteria.
Obesity Guideline Version 3 February 2012
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Appendix 3
Monitoring Compliance
In order to monitor compliance with this guideline, this guideline will be monitored as follows:
Minimum requirements
a) The calculation and
recording of the body mass
index (BMI) for all women
b) The calculation of the body
mass index(BMI) and recording
of the BMI in the electronic
patient information system
c) That all women with a
BMI≥30 should be advised to
book for maternity team based
care
d) That all women with ≥35
should be advised to deliver in
an obstetric led unit
e) An agreed BMI at which
women must be offered an
antenatal assessment with an
obstetric anaesthetist
Guideline Statement
Evidence
All pregnant women must have an accurate measurement of
height and weight taken at their booking visit and BMI
calculated. They also need to be re- weighed again at 36
weeks. These measurements must be clearly documented in
the patient notes.
Notes audit
These measurements must be clearly documented in the
women’s hand held notes and electronic patient information
system.
Notes audit
At the GTT appointment consideration will be given regarding
midwifery led care or consultant led care. Women with a BMI
≥30 at booking are not currently booked for Consultant led
care due to resources.
Notes audit.
Women with a BMI ≥ 35 must be referred to a consultant
obstetrician for Consultant led care. These women are not
suitable for midwifery led care and should be advised to
deliver in hospital with appropriate neonatal services.
Notes audit
Women with BMI ≥40 at booking should be referred to the
Lead Obstetric Anaesthetist irrespective of the planned mode
of delivery.
Notes audit.
Obesity Guideline Version 3 February 2012
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CNST
standards
3.10
3.10
3.10
3.10
3.10
f) That an obstetric anaesthetic
management plan for labour
and delivery should be
discussed with the woman and
documented in the health
record.
g) That all women with a BMI
≥30should have an antenatal
consultation with an obstetric
consultant to discuss possible
intrapartum complications, the
discussion must be
documented in the health
record
h) The requirement to assess
the availability of suitable
equipment in all care settings
for women with a high BMI
An individualised management plan should be written in the
woman’s maternity notes and any specialised equipment
identified.
Notes audit.
3.10
At the GTT appointment consideration will be given regarding
midwifery led care or consultant led care. Women with a BMI
≥30 at booking are not currently booked for Consultant led
care due to resources.
Notes audit.
3.10
A clear plan of care should be written in the patient maternity
notes and any specialised equipment identified. Suitable
equipment e.g. large chairs, wheelchairs are available
throughout the Trust for further information refers to Bariatric
Guidelines in the Manual Handling Resource Pack or contact
one of the Manual Handling link midwives or Trust equipment
co-ordinator. Also see (Appendix 1) Maximum Load Weight of
Equipment and (Appendix 2) Guideline for use of equipment
for overweight patients. This equipment will be assessed
annually by the Manual Handling Link Midwives.
Obesity Guideline Version 3 February 2012
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Notes audit.
3.10