Guideline No. 392-Pregnancy and Maternal Obesity Part 2: Team Planning for Delivery and Postpartum Care

• Published in: Journal of obstetrics and gynaecology Canada Vol. 41; no. 11; pp. 1660 - 1675
• Main Authors: Maxwell, Cynthia, Gaudet, Laura, Cassir, Gabrielle, Nowik, Christina, McLeod, N. Lynne, Jacob, Claude-Émilie, Walker, Mark
• Format: Journal Article
• Language: English
• Published: Netherlands Elsevier Inc 01.11.2019
• Subjects: Caesarean birth; Canada; Female; fetal ultrasound; fetal/neonatal morbidity; gestational weight gain; Humans; labour and delivery; maternal morbidity; maternal obesity; Obesity; Patient Care Team - standards; Pregnancy; Pregnancy Complications; Prenatal Care - standards; Societies, Medical; stillbirth; vaginal birth; vaginal birth after Caesarean; venous thromboembolism; weight loss surgery; wound disruption; Canada; fetal/neonatal morbidity; maternal obesity; maternal morbidity; VBAC; VTE; weight loss surgery; stillbirth; fetal ultrasound; wound disruption; gestational weight gain; vaginal birth; Pregnancy; Caesarean birth; venous thromboembolism; IUDs; DMPA; vaginal birth after Caesarean; labour and delivery; BMI
• ISSN: 1701-2163
• DOI: 10.1016/j.jogc.2019.03.027

This guideline will review key aspects in the pregnancy care of women with obesity. Part I will focus on Preconception and Pregnancy Care. Part II will focus on Team Planning for Delivery and Postpartum Care. All health care providers (obstetricians, family doctors, midwives, nurses, anaesthesiologists) who provide pregnancy-related care to women with obesity. Women with obesity who are pregnant or planning pregnancies. Literature was retrieved through searches of Statistics Canada, Medline, and The Cochrane Library on the impact of obesity in pregnancy on antepartum and intrapartum care, maternal morbidity and mortality, obstetric anaesthesia, and perinatal morbidity and mortality. Results were restricted to systematic reviews, randomized controlled trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to September 2018. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. The content and recommendations were drafted and agreed upon by the authors. Then the Maternal-Fetal Medicine Committees peer reviewed the content and submitted comments for consideration, and the Board of the Society of Obstetricians and Gynaecologists of Canada (SOGC) approved the final draft for publication. Areas of disagreement were discussed during meetings at which time consensus was reached. The level of evidence and quality of the recommendation made were described using the Evaluation of Evidence criteria of the Canadian Task Force on Preventive Health Care. Implementation of the recommendations in these guidelines may increase obstetrical provider recognition of the issues affecting pregnant individuals with obesity, including clinical prevention strategies, communication between the health care team, the patient and family as well as equipment and human resource planning. It is hoped that regional, provincial and federal agencies will assist in the education and support of coordinated care for pregnant individuals with obesity. SOGC guideline will be automatically reviewed 5 years after publication. However, authors can propose another review date if they feel that 5 years is too short/long based on their expert knowledge of the subject matter. This guideline was developed with resources funded by the SOGC. 1Unfavourable cervix and induction of labour are more common with maternal obesity. The role of induction of labour and risk of Caesarean birth remains unclear (II-2).2Electronic fetal monitoring is recommended for women in active labour with a body mass index >35 kg/m2. Cervical assessment, uterine monitoring, and fetal heart rate monitoring may be more challenging with higher degrees of maternal body mass index (III).3Decision-to-delivery time is increased in women with obesity (II-2).4Body mass index increases risk of surgical site infection and wound complications (II-2).5Anaesthetic risks are increased with maternal obesity (II-2).6Rates of successful breastfeeding are reduced for women with obesity (II-2).7Several effective contraceptive choices are available to women with obesity (III).8Women with obesity are at higher risk of postpartum depression and anxiety (II-2).9Antenatal, labour and delivery, and postnatal care may be more complex in women with obesity (III). 1Electronic fetal monitoring is recommended for women in active labour with a body mass index >35 kg/m2. Intrauterine pressure catheters may assist in assessment of labour contractions. Fetal scalp electrodes may be helpful to ensure continuous fetal monitoring when indicated (III B).2Women with obesity may benefit from higher dosage of preoperative antibiotics for Caesarean birth (I A).3It is recommended to reapproximate the subcutaneous tissue layers at the time of Caesarean birth to reduce wound complications (II-2 A).4Antenatal assessment with obstetric anaesthesia may assist in planning for safer birth for women with obesity (III A).5Postoperative thromboprophylaxis is recommended, at appropriate dosing for the given body mass index, due to the greater risk of venous thromboembolism following Caesarean birth with women with obesity (II-3 A).6Women with obesity should be offered lactation support in the postpartum period (III C)7Women with obesity should be screened for postpartum depression and anxiety given that maternal obesity is a risk factor for these conditions (II-2 A).8Counselling regarding weight management in the postpartum period is suggested in order to minimize risks in subsequent pregnancies (II-2 A).9Obstetric team planning may be helpful for women with obesity to navigate the steps in antenatal, labour and delivery, and postnatal care (III-3 A).