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RISING RATES of obesity, especially among women of childbearing age, are affecting maternal-fetal outcomes; about 25% of women ages 20 to 44 are obese.1-3 Women who are obese or morbidly obese face an extremely high risk of developing health problems before, during, and after pregnancy.4 (See What's obesity?)
Effective interventions are needed because maternal obesity is now one of the most commonly occurring obstetric risk factors, with research showing limited long-term improvements with current interventions.5,6 Bariatric surgery, presently the only evidence-based treatment for morbid obesity, shouldn't be performed during pregnancy or in the immediate postpartum period.7 (See Special considerations for patients who become pregnant after bariatric surgery.)
This article addresses the health risks of obesity to mother and baby during pregnancy, labor, and delivery and discusses what you can do to mitigate those risks.
Obesity involves physical, mental, and emotional factors. Before addressing a patient's excess weight, you need to understand the issues involved and how the patient feels about her weight and ability to change it.8 Even though effective nursing interventions for preventing obesity-related complications in pregnancy are limited, you can have a substantial impact on the quality of care and patients' perception of their care if you approach the issue in a sensitive way.9
A good beginning goes a long way toward building a positive healthcare relationship. If you take the initial history and intake information for a pregnant woman who's obese, establish a positive and nonjudgmental atmosphere from the very first visit. A trusting relationship may help sustain the patient's willingness and desire to seek prenatal care as well as to make healthy lifestyle changes.
Obtain the weight and height of all pregnant patients at the first prenatal visit, adding obesity to the problem list for patients as appropriate. Assess their knowledge about nutrition, exercise, and the implications of obesity. Also, ask about their maximum nonpregnant lifetime weight. Ask patients if they're trying to lose weight right now and about their typical diet. Evaluate previous and current weight-loss attempts and assess for disordered eating behavior, including the use of stimulants, diuretics, laxatives, vomiting, binge eating, or anorexia nervosa.8
Tell patients whose prepregnancy BMI is 30 or more to consume at least 1,500 kcal/day. Patients whose prepregnancy weight was stable should consume an additional 100 kcal/day.2 Emphasize gaining an appropriate, but not excessive, amount of weight.3 The American College of Obstetricians and Gynecologists (ACOG) and the Institute of Medicine (IOM) both recommend a total prenatal weight gain of 11 to 20 lb for women who are obese and 15 to 25 lb for women who are overweight.10 (See New recommendations for weight gain during pregnancy.) Refer the patient for assessment and monitoring by a registered dietitian or nutritionist, if appropriate.
All pregnant women with a BMI of 30 or more should have a prenatal discussion with their provider about possible intrapartum complications and appropriate management strategies. The discussion should be documented in the medical record.5
All prenatal patients with a BMI over 40 should have a consultation with an obstetric anesthesiologist to identify potential issues with venous access and regional or general anesthesia. An anesthesia management plan should be developed and documented in the medical records.5 These patients should also have a labor pain management plan.11
During interactions with healthcare professionals, patients may be experiencing distress and self-judgment. Be sure to deliver information in a kind, factual, and nonjudgmental manner, and encourage questions. Most overweight patients are sensitive about their size. Pregnant women who are obese describe a constant awareness of their size and negative experiences with healthcare professionals, and frequent healthcare interactions may exacerbate the distress of these women.12,13
Your spoken and written references to weight should be informative but not judgmental. Even inadvertently negative remarks about the patient's size (for example, a comment that the patient's size will make an ultrasound procedure more difficult) can be emotionally devastating, causing embarrassment, guilt, and self-blame, and creating a barrier to seeking care.13
Include positive and affirming comments about the pregnancy.13 Asking about the ultrasound images, nursery preparations, and the baby shower will convey your caring and support with a positive interaction about the pregnancy. Teach these patients that taking care of themselves will improve their baby's health.
Be aware of your own feelings when caring for these patients. When people are perceived as having undesirable characteristics, such as being too lazy or irresponsible to take care of themselves or their babies, it becomes very easy for healthcare professionals to set them apart and allow them to be devalued and treated with discrimination.13
Several researchers have reported substandard maternity care for obese patients. Self-reports from obstetric and general practice providers indicate a strong negative attitude toward this group of patients.12,14
Now consider some specific hazards of pregnancy that women who are obese may face.
The most common risk factor for unexplained stillbirth is prepregnancy obesity.4 Higher rates of stillbirth may be related to medical complications associated with the pregnancy and obesity.15
Women with a BMI of 30 or more are at increased risk for early (less than 12 weeks) and recurrent (three or more times) spontaneous abortion.16,17 High adiposity contributes to insulin resistance and subsequent hyperglycemia, as well as a dysregulated release of inflammatory and prothrombotic factors, which may contribute to higher rates of early and recurrent spontaneous abortion.18,19
Clinical implications. Because the incidence of spontaneous abortion is generally lower with improved insulin sensitivity, some providers advocate for treatment with insulin-sensitizing agents, such as metformin, to minimize insulin resistance and the subsequent hormonal cascade.19 Invasive testing such as amniocentesis is generally avoided: Difficulties with the procedure due to adiposity are associated with higher rates of postprocedure amniotic fluid leakage and spontaneous abortion for women with higher BMIs.11
Because of the two- to fourfold increase in stillbirth risk, third trimester nonstress tests and daily kick counts may be recommended for your patient.15 (See Close-up on four tests.) Help educate patients about their increased risk as well as the signs and symptoms associated with spontaneous abortion or stillbirth.3 Patients should immediately report bleeding, heavy cramping, or decreased fetal movement.
The risk of developing gestational diabetes mellitus (GDM) is positively correlated with maternal weight and is one of the most significant risk factors for pregnant women who are obese. Women with GDM are also at risk for concurrently developing hypertensive disorders such as pregnancy-associated hypertension because both conditions seem to have the same underlying pathophysiology.2
Pregnant women normally have decreased peripheral tissue sensitivity to insulin in late pregnancy, but women who are obese have a substantially larger decrease, which may occur earlier.20 Pregnant women with a BMI of 25 to 30 are up to six times as likely to develop GDM as women with a normal BMI, and pregnant women with a BMI over 30 are up to 20 times as likely to develop GDM.11 Those with an android fat distribution are considered apple shaped and store fat around their abdomen. This group has a high waist-to-hip ratio and is at the greatest risk for developing GDM.2 Women who are obese and develop GDM are also twice as likely to develop type 2 diabetes later in life.17,18
Clinical implications. According to the American Diabetes Association (ADA), pregnant women who have risk factors for GDM, such as obesity, a strong family history of diabetes, or previous delivery of a baby weighing more than 9 lb, should be screened in the first trimester or at the first prenatal visit to assess for pre-GDM.
The preferred method for screening and the appropriate cutoff for diagnosis are somewhat controversial. The ADA and other organizations have recently endorsed the use of a single 75-g oral glucose tolerance test (OGTT) for diagnosis of GDM. Plasma glucose levels are measured when the patient is fasting and then at 1 and 2 hours after consuming the glucose load. If fasting levels are 92 mg/dL or higher, 1-hour levels are 180 mg/dL or higher, or 2-hour levels are 153 mg/dL or higher, the patient is diagnosed with GDM.21
ACOG continues to support the use of the two-step approach to screening and diagnosis, which involves drinking a 50-g oral glucose solution and having plasma glucose values measured 1 hour later. If this screening glucose value is greater than 130 or 140 mg/dL (depending on practice preference for sensitivity), a 3-hour, 100-g OGTT is performed. If two or more values are elevated (fasting levels are 95 mg/dL or higher, 1-hour levels are 180 mg/dL or higher, and 3-hour levels are 140 mg/dL or higher), the patient is diagnosed with GDM.22 Some practitioners who use the two-step process may choose to implement dietary and educational interventions if only one level of the 3-hour, 100-g OGTT is elevated because this is also associated with maternal-fetal complications.20
If a first-trimester glucose screen isn't done or is negative, patients' fasting plasma glucose and postprandial glucose levels should be monitored monthly. Also, anticipate glucose screening as described above at 24 to 48 weeks gestation.2
Women who are diagnosed with GDM may be upset and frightened, so be prepared to offer emotional support. Encourage women with GDM to increase their physical activity as tolerated: Exercise helps lower blood glucose by encouraging its uptake and use by muscle tissue. Swimming, water aerobics, and upper extremity exercise such as rowing are particularly beneficial.2 Brisk walking programs (30 to 40 minutes, 3 to 4 times/week) have been used by patients with GDM, resulting in better glycemic control and a decreased need for exogenous insulin.4
Refer the patient to a registered dietitian or certified diabetes educator for teaching about how to manage her blood glucose, such as eating a high-fiber, low-glycemic index diet.20 Teach the patient to monitor her blood glucose levels, count carbohydrates, and recognize signs and symptoms of hyperglycemia and hypoglycemia. (See Recognizing hyperglycemia and hypoglycemia.) The patient may be prescribed medication to stabilize her blood glucose. Strictly controlling blood glucose levels and monitoring A1C levels each trimester will minimize complications and decrease the risk of hypertensive disorders.23
Once the patient has delivered and is no longer pregnant (about 6 weeks postpartum), both the ADA and ACOG agree that all women with a BMI of 30 or above who were diagnosed with GDM should have a 75-g OGTT.21,24 Teach them to follow up with their primary care provider for evaluation of cardiometabolic risk and development of type 2 diabetes.5,24
Pregnancy-induced hypertension (PIH) and preeclampsia are 50% more likely to occur in obese women than in women of normal weight.7 PIH is diagnosed with the onset of systolic BP of 140 mm Hg or higher or diastolic BP of 90 mm Hg or higher after the 20th week of gestation in a woman who previously had normal BP. The BP reading should be repeated and documented after at least 6 hours.7,17 Preeclampsia, which affects about one in five pregnant women who are obese, involves PIH with the addition of proteinuria (above 300 mg/24 hours).
HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets) is a complication of PIH. The risk of thromboembolic events is already elevated in people who are obese, and the presence of hypertensive disorders further increases this risk.2
Clinical implications. At each visit, monitor the patient's BP, along with signs and symptoms of organ involvement such as severe headaches, vision changes, epigastric pain, and oliguria.2 A baseline 24-hour urine collection for protein/creatinine ratio and serum creatinine, liver enzymes, and platelet count may be ordered in the first trimester or with the onset of gestational hypertension. These values should be monitored as needed throughout the pregnancy.2 Hypertension is generally asymptomatic, but teach your patients to report new or unusual signs and symptoms such as vision changes, headaches, ecchymoses, or unusual bleeding.
Pregnant women who are obese are more likely to go past the normal 40 weeks of pregnancy, and once they're in labor, to have slower and less productive labor progression. Adipose tissue produces leptin, a hormone that sends a signal to the brain when the body's had enough to eat. Leptin also inhibits contractions, decreasing the occurrence and strength of spontaneous and oxytocin-induced contractions.11 This hormonal imbalance increases the risk that labor will have to be induced and the risk of failure to progress, resulting in higher cesarean section rates.11
Clinical implications. A baseline first-trimester ultrasound should be ordered to establish an accurate fetal gestational age and due date for the pregnancy. Accurate assessment of fetal growth and need for labor induction rely heavily on correct estimates of gestational age. Women with a BMI over 35 should deliver in a hospital with appropriate neonatal and anesthesiology services.5 In the absence of other complications, obesity isn't an indication for induction or cesarean section.5
If external fetal monitoring (performed by placing electrodes on the skin that are connected to monitors) isn't successful, fetal heart tones and contraction strength may be monitored with a fetal scalp electrode and an internal uterine pressure catheter.4 Your facility should have protocols to establish venous access in all women with a BMI over 40. Anticipate active management of the third stage of labor; this involves the administration of oxytocin, controlled cord traction, and fundal palpation. This technique decreases the risk of postpartum hemorrhage due to uterine atony in women with a BMI over 30.5 Continue to assess for postpartum hemorrhage, which may cause vertigo, syncope, lightheadedness, hypotension, oliguria, and tachycardia during the postpartum period.
Compared with the risk of cesarean section in women of normal weight, the risk is 1.4 times higher for overweight women, 1.5 times higher for obese women, and 3.1 times higher for very obese women.4 Women having a cesarean section have higher rates of complications, including blood loss, infection, and thromboembolic events, resulting in longer postoperative recovery times.2 Overweight women who have a cesarean section are two to three times as likely to develop a surgical site infection.2
Regional anesthesia can be difficult to administer because bony landmarks can't be identified and positioning is more difficult. Longer needles may be required to reach the epidural and spinal spaces.11 General anesthesia carries an increased risk due to difficulties with endotracheal intubation, a tendency to desaturate quickly, and an increased risk of aspiration in these patients.2
Clinical implications. Your facility should have OR tables and equipment that accommodate obese patients. Assess accessibility, including doorway widths and weight limitations of equipment. Large BP cuffs, chairs without arms, large wheelchairs, and appropriate-size gowns should be available.5 Additional surgical instruments and assistants may be required to ensure adequate visualization.
Be aware that healthcare staff can be injured when they move an obese patient, particularly if the patient is anesthetized.11 Follow your facility's policy regarding using mechanical devices to lift and transfer patients. Be aware that more time may be required to transport the patient, prepare the OR, establish anesthesia, and perform the procedure.4
Women who have a BMI of 30 or more are at greater risk for postpartum infection such as endometritis. Those who undergo a cesarean section should receive prophylactic antibiotics at weight-appropriate dosages at the time of the surgery to decrease the risk of postoperative wound infection.5
Teach your patient to monitor incisions for signs and symptoms of infection or dehiscence.3 Due to the overlying pannus, patients may not be able to visualize their incision; they may require your assistance for cleaning and packing incisions for healing by secondary intention.3
Educate women who've had a cesarean section about the risks of future pregnancies. Vaginal birth after cesarean section success rates for women who are obese range from 54% to 68% but may be as low as 13% in women over 300 lb.4
Pregnant women who are obese have a venous thromboembolism (VTE) incidence of 2.5%; the incidence is only 0.6% among pregnant women who aren't obese.4 Pregnant women who are obese also face an increased risk of recurrent VTE.19
Clinical implications. Women with a BMI of 30 or more should be assessed for VTE risk throughout their pregnancy. Assess monthly for signs and symptoms of lower extremity venous stasis.2
Encourage early ambulation and adequate hydration after delivery in addition to assessing for signs and symptoms of deep vein thrombosis and pulmonary embolism. Your facility should use a systematic approach to identify patients at risk for VTE, including pregnant women who are obese. Administer VTE prophylaxis as prescribed if the patient is 35 or older and has a BMI of 30 or more, or younger with a BMI over 40.5,11 Teach your patient to recognize and immediately report signs and symptoms of VTE, a leading direct cause of maternal mortality.19
Pregnant women who are obese may be prescribed intermittent pneumatic compression (IPC); assess for appropriate fit, application, and use. The circulating nurse should also ensure that IPC is initiated during cesarean sections if time allows.11
Women who are obese and have cesarean sections should have appropriately dosed thromboprophylaxis after the surgery.11 Protocols for thromboprophylaxis should include those specifically for obese and morbidly obese women to ensure adequate dosing.25
Obesity is linked to birth defects, including spina bifida, cardiac malformations, diaphragmatic hernia, and multiple anomalies.19
A folic acid intake of 400 mcg, which protects women of normal body weight from having infants with neural tube disorders, isn't adequate for overweight or obese women.19 Teach women who have a BMI of 30 or more to take additional folic acid daily as prescribed before conception and throughout the first trimester of pregnancy.5
Ultrasound studies are technically difficult to perform in these patients. Fetal heart structures and craniospinal structures may be difficult to visualize. Many first-trimester screens can't be successfully completed.2
Clinical implications. Patients should be offered the first-trimester screen and triple screen with appropriate counseling. Patients should be told in a sensitive way that the reports generated from these studies may have limitations.
Patients may exhibit increased anxiety when discussing the risk of and tests for birth defects. During these moments, the "teach back" approach may help you ensure that the patient understands the material being presented. Asking the patient to explain the tests offered and why they're being done may help assess the patient's understanding. Following the "teach back," ask the patient how she's feeling about the procedures she's discussed and make sure any remaining questions are addressed.
The risk of delivering an infant weighing over 4,000 g, or above the 90th percentile (macrosomia), is 1.7 to 2 times higher for women who are obese or morbidly obese; the chance of delivering an infant weighing over 4,500 g is 2 to 2.4 times higher.4
Although only 0.2% to 3% of all infants have a shoulder dystocia at delivery, more than a third of infants weighing over 4,500 g have this complication.17 (See Picturing a shoulder dystocia.)
Infants of women who are obese are more likely to be admitted to the neonatal ICU for obstetric trauma and low Apgar scores.2 Fetal macrosomia is also a risk factor for labor induction and cesarean section.4
Macrosomic infants have a high risk of developing childhood obesity and glucose intolerance in adulthood related to in utero exposure and possible modulation of gene expression.2
Clinical implications. Help women monitor their weight at the beginning of and throughout the pregnancy. Closely monitor for GDM; if it develops, help educate patients to maintain tight glycemic control through dietary measures, blood glucose monitoring, and appropriate administration and timing of prescribed medications. If assessing the infant's size is difficult due to adiposity, a fetal growth ultrasound can be used throughout the pregnancy but is associated with a higher cesarean section rate; 77% of these studies overestimate fetal weight.4 At the time of delivery, be prepared for shoulder dystocia interventions as well as postpartum hemorrhage control measures.
In addition to the benefits for the newborn, breastfeeding can play a critical role in postpregnancy weight reduction and maintenance. But women who are obese have lower prolactin levels, which can make initiating and maintaining breastfeeding more difficult.26
Clinical implications. Early initiation of breastfeeding helps promote the production of prolactin and oxytocin while skin-to-skin contact and rooming-in, or keeping the mother and infant together, help encourage frequent feedings and the development of breast milk. If you're a postpartum nurse, you'll regularly assess the mother and infant and assist with breastfeeding. Help the mother to a comfortable position and ensure that the infant can latch on appropriately.
Refer the patient to a lactation consultant if needed. Developing a lactation support plan and providing frequent clinic visits or telephone support after discharge may also help prevent early discontinuation of breastfeeding.26
After delivery, advise women with a prenatal BMI of 30 or more to continue working with a dietitian or nutritionist to attempt to normalize weight. Besides encouraging them to breastfeed, advise them to start a regular program of exercise. Select interventions with the patient, monitoring them in a positive and encouraging way.
Obesity is associated with depression, social isolation, work absences, and anxiety in patients who aren't pregnant.8 These issues may have even more impact during pregnancy. Emphasizing the medical management and risks of pregnancy in obese patients may exacerbate these conditions.13 As you encourage and support your patient, try to maintain an appropriate balance of education and concern.
Women who are obese may also have trouble breathing while sleeping. Obstructive sleep apnea and sleep interruption may contribute to chronic fatigue and cardiovascular risk and impact the patient's psychological state.8 Pregnancy may precipitate or exacerbate obstructive sleep apnea.
Clinical implications. Overeating is frequently associated with emotional factors so be sure pregnant patients who are obese are screened and their psychological state is being followed appropriately.3 Identifying emotional issues may help the patient take further steps such as psychological counseling, using alternative stress reduction methods, or seeking additional family or cultural resources for support.8
Many women who are obese report sexual, physical, or psychological abuse in their childhood. This abuse may contribute to the challenges experienced during pregnancy.8 Women with identified emotional or abuse issues or disordered eating behaviors should be referred for treatment. Collecting this information in a sensitive and nonjudgmental manner may help them disclose troubling information.12
When pregnant patients are obese and report chronic fatigue or depression, assess them for sleep apnea and sleep interruption.8
Caring for pregnant patients who are obese may be challenging, complicated, and at times frustrating. Continually assess your own biases and attitudes and provide professional evidence-based care for all women. Providing appropriate and sensitive care will help ensure the best possible outcomes for women and their infants.
Weight classifications are based on clinical assessments of height and weight before and at the first prenatal visit and determine a patient's body mass index (BMI), which is body weight in kilograms divided by height in meters squared (kg/m2). A BMI over 25 but 29.9 or less is considered overweight. The World Health Organization and the IOM both define obesity as a BMI greater than 29.9 with increasing values of BMI associated with increasing health risks and complications.4 Those with a BMI over 40 are classified as severely or morbidly obese.
In the United States, 25% of women ages 20 to 44 are overweight and 25% are obese.3 In women ages 12 to 44, obesity rates have more than doubled since the 1970s, and rates of morbid obesity have increased threefold.18
The disease burden created by obesity isn't felt equally among all populations. White non-Hispanic women have obesity rates of 23% while Black non-Hispanic women have rates of 39%.3 In addition, obesity rates among women who didn't complete high school are almost double the rates of women who have completed college, and women with low socioeconomic status are 50% more likely to be obese than those with higher socioeconomic status.3,11
Patients who've had bariatric surgery before pregnancy may need additional nutritional assessment and education to ensure adequate intake. Depending on the type of surgery, previous bariatric surgery may increase the risk of vitamin B12 deficiency, anemia, hypokalemia, hyponatremia, hypoglycemia, hypoalbuminemia, and some severe vitamin-deficiency states.2 Patients with a history of bariatric surgery who now have a normal prepregnancy BMI have a decreased risk of gestational diabetes, hypertensive disorders, macrosomia, and operative delivery.2,7
Monitor clinical and ultrasound assessments for fetal growth; patients with adjustable gastric bands may need to have the bands deflated during pregnancy to allow for normal weight gain and favorable maternal outcomes.2,5 An early consultation with a bariatric surgeon is recommended for these patients.24
The first-trimester screen and triple screen help determine the risk of fetal abnormalities.
* The first-trimester screen combines maternal blood tests with a fetal ultrasound to evaluate risk for Trisomy 21, Trisomy 18, or other birth defects, including cardiac disorders. A negative screen indicates a low risk for these disorders, and a positive screen indicates a high risk. Follow-up diagnostic testing is recommended for patients with positive screens.
* The triple screen, which involves maternal blood tests to evaluate the level of three pregnancy hormones (alpha-fetoprotein, hCG [human chorionic gonadotropin], and estriol), is very dependent on accurate dating. High levels indicate an increased risk for spina bifida, anencephaly, or esophageal or abdominal birth defects. Low levels indicate an increased risk of Trisomy 21, Trisomy 18, or other genetic abnormalities.
Nonstress tests and daily kick counts are two noninvasive tests performed in the third trimester to assess fetal well-being.
* In nonstress tests, external monitors are applied to the pregnant patient's abdomen. These record the fetal heart rate and any contraction activity. A reactive test result indicates the fetal heart rate increases with fetal movement. This is a reassuring sign in terms of fetal oxygenation.
* When a patient is asked to perform daily kick counts, she records the length of time it takes to experience 10 fetal movements. It should be 2 hours or less. Decreased fetal movement should be noted and reported immediately.
Signs and symptoms of hyperglycemia include:
Signs and symptoms of hypo glycemia include:
* sudden moodiness or behavior changes, such as crying for no apparent reason
* clumsy or jerky movements
* difficulty paying attention or confusion
* circumoral paresthesias.
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