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Abstract
Objective Despite the growing prevalence of obesity among reproductive aged persons in the USA, evidence-based guidelines for peripartum care are lacking. The objective of this scoping review is to identify obesity-related recommendations for peripartum care, evaluate grades of evidence for each recommendation, and identify practical tools (eg, checklists, toolkits, care pathways and bundles) to support their implementation in clinical practice.
Data sources We searched MEDLINE, EMBASE, CINAHL, the Cochrane Central Register of Controlled Trials and ClinicalTrials.gov from inception to December 2020 for eligible studies addressing peripartum care in persons with obesity.
Study eligibility criteria Inclusion criteria were published evidence-rated recommendations and practical tools for peripartum care of persons with obesity.
Study appraisal and synthesis methods Pairs of independent reviewers extracted data (source, publication year, content and number of recommendations, level and grade of evidence, description of tool) and identified similarities and differences among the articles.
Results Of 18 315 screened articles, 18 were included including 7 articles with evidence-rated recommendations and 11 practical tools (3 checklists, 3 guidelines, 1 care bundle, 1 flowchart, 1 care pathway, 1 care map and 1 protocol). Thirteen of 39 evidence-rated recommendations were based on expert opinion. Recommendations related to surgical antibiotic prophylaxis and subcutaneous tissue closure at caesarean delivery received the highest grade of evidence. Some of the practical tools included a checklist from the USA regarding anticoagulation after caesarean delivery (evidence-supported recommendation), a bundle for surgical site infections after caesarean delivery in Australia (evidence did not support recommendation) and a checklist with content for several aspects of peripartum care from Canada (evidence supported seven of nine definitive recommendations).
Conclusion The recommendations for peripartum care for persons with obesity are based on limited evidence and few practical tools for implementation exist. Future work should focus on developing practical tools based on high-quality studies.
- OBSTETRICS
- Maternal medicine
- PERINATOLOGY
Data availability statement
The protocol is available for review at https://doi.org/10.18131/g3-gyms-ww23https://doi.org/10.18131/g3-gyms-ww23. A full list of the sources and search strategies is outlined in online supplemental appendix A. The protocol is available for review at https://doi.org/10.18131/g3-gyms-ww23https://doi.org/10.18131/g3-gyms-ww23. A full list of the sources and search strategies is outlined in online supplemental appendix A. The remainder of the data are available on reasonable request (ie, articles reviewed via covidence system).
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STRENGTHS AND LIMITATIONS OF THIS STUDY
We may not have identified all articles with evidence-rated recommendations, though our search of available published literature was thorough including a search of appropriate web sites.
Sites may have practical implementation tools that they use in the short term or long term, but they may not be published or available in a more public domain.
Although topics such as contraception and postpartum weight management are important in the postpartum care of persons with obesity, they were not specifically addressed in this review, which pertained to peripartum care in the immediate postpartum period.
Obesity was typically defined according to a body mass index (BMI) ≥ 30.0 kg/m2, but in many instances the timing of the BMI was not provided (eg, prepregnancy vs at delivery).
We did not include recommendations that were intended for patient education only in this review.
Introduction
Obesity has reached epidemic proportions in the USA.1 In 2015–2016, non-Hispanic black (54.8%) and Hispanic (50.6%) women had the highest prevalence of obesity and 36.5% of reproductive age women (20–39 years) had obesity (body mass index, BMI ≥30.0 kg/m2), translating to a high percentage of persons with obesity during future pregnancies and race-ethnicity health disparities.2 Of further concern, over 50% of persons with obesity exceed guidelines for weight gain during pregnancy, thus compounding their risks for adverse outcomes.3–5 Adverse peripartum outcomes associated with obesity include caesarean delivery, infection, haemorrhage, venous thromboembolism (VTE) and anaesthesia-related complications, such as failure of regional anaesthesia and respiratory depression.6 These adverse outcomes are amplified in persons with a BMI ≥50 kg/m2.7 Furthermore, obesity is cited as a contributing factor in over 50% of maternal deaths.8
Adaptations to prenatal care for persons with obesity include early screening for diabetes and limiting weight gain to 11–20 pounds.9 However, more evidence-based studies for peripartum care of persons with obesity, where the risk for adverse outcomes is a significant concern, are needed. For example, the National Institute for Health and Care Excellence performed evidence-based reviews for the intrapartum management of obesity in 2019 and found no clinical evidence to suggest that the management of fetal monitoring or maternal positioning in labour should be altered.10 Even fewer studies and evidence-based recommendations are available for those with a BMI ≥50 kg/m2, who are at even higher risk for adverse outcomes.
Strategies that have reduced adverse outcomes in obstetrics include the development of checklists or toolkits after identifying patient, provider and systems factors for improvement in the care pathway.11 Given the increasing incidence of obesity and obesity-related complications, it is critical to identify opportunities to improve the safe delivery of peripartum care.
Objectives
The objective of this scoping review is to identify obesity-related recommendations for peripartum care, evaluate levels or grades of evidence for each recommendation, and identify practical tools such as checklists, toolkits or other comprehensive care pathways to support their implementation in clinical practice. In this scoping review, we were specifically interested in recommendations that pertained to actionable items such as a treatment or decision option or a specialised consultation.
Methods
Eligibility criteria, information sources, search strategy
The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews checklist was used in developing and reporting this scoping review.12 The inclusion criteria were: (1) published (in print or online) recommendations along with levels or grades of evidence for the peripartum care of persons with obesity (BMI ≥30.0 kg/m2), and if possible, specifically for persons with a BMI ≥50 kg/m2 or (2) published (in print or online) description of a tool such as a checklist, toolkit or comprehensive care pathway for the peripartum care of obesity. We defined peripartum care to refer to care immediately before, during and after delivery, approximately 24 hours before and after delivery. To be included in the review, the identified recommendations needed to focus on actionable items or management strategies, as opposed to being a listing of comorbidities or risks that are associated with obesity in pregnancy. Actionable items might include giving or withholding a particular medication or device. Recommendations that exclusively related to ‘patient counselling’ or imparting of knowledge to the patient were not included as the interpretation of counselling can have different meanings depending on the clinical setting (eg, location of clinical practice, provider type). The recommendations could have been abstracted from articles pertaining to obesity alone, or other articles that specified recommendations pertaining to obesity (eg, antibiotic use in pregnancy with a specific adaptation for persons with obesity). Because recommendations could be published from varying healthcare systems and there were no restrictions placed on country of origin (eg, national guidelines from USA vs UK), variances in evidence grading were identified and abstracted according to the healthcare system’s grading method.
We searched PubMed MEDLINE, Embase (embase.com), Cochrane Central Register of Controlled Trials (Wiley), CINAHL (EbscoHost) and ClinicalTrials.gov from inception to December 2020, with no date or language restrictions. The search for eligible studies involved controlled vocabulary (MeSH headings and thesauri of relevant databases) and the keywords of obesity, morbid obesity, super morbid obesity, guidelines, recommendations, checklist, toolkit, maternal care pathway, peripartum care and pregnancy. The bibliographies of relevant reviews were handsearched, as well as key websites including Google Scholar. A full list of the sources and search strategies is outlined in online supplemental appendix A.
Supplemental material
Patient and public involvement
Patients were not directly involved in the design of this study.
Study selection
The questions for this scoping review were: (1) What are the recommendations for peripartum care of persons with obesity published by either individual authors, national societies or other government departments that provide levels or grades of evidence to support the recommendation? and (2) What are the published tools for practical implementation of recommendations, either in the form of checklists, toolkits or other comprehensive care pathways?
The primary outcomes were the number of recommendations per article, topic of recommendation, level or grade of evidence to support recommendations and similarities and differences between the recommendations across articles. For the identified checklists, toolkits or other comprehensive care pathways for the peripartum management of obesity, their details were summarised and crosschecked with the aforementioned recommendations.
Data extraction
Four reviewers independently screened all citations using the Covidence review management software.13 Initially, the reviewers were trained on a sample of 20 articles using the Covidence software to verify clarity and consistency regarding inclusion and exclusion criteria. A separate, fifth reviewer resolved all conflicts. Once agreement was obtained on articles meeting criteria for final inclusion, two reviewers independently extracted the following data from each article using a form that was tested and modified by the reviewers, as applicable: (1) source of recommendations (eg, individual authors, national societies), (2) year of publication, (3) content and total number of recommendations, (4) level and grade of evidence for each of the recommendations, (5) system used to determine levels of evidence or classification of recommendations and (6) description of checklist, toolkit, comprehensive care pathway or other format used for implementation in the peripartum care of obesity. If articles were in abstract form only, we contacted the authors for updates on the status of the final publication.
Data synthesis
The data were summarised and abstracted into table format, noting key similarities and differences among the articles in terms of content and level and grade of evidence. For the identified checklists, toolkits, etc similarities and differences among the content were highlighted. For this scoping review, we did not assess the effectiveness of the findings or evaluate bias. The scoping review protocol is published at https://doi.org/10.18131/g3-gyms-ww23.
Results
Study selection
After removal of duplicates, 18 328 articles were screened, resulting in 203 articles for full-text review. Figure 1 shows the flow diagram for study selection. A total of 7 evidence-rated articles and 11 tools met inclusion criteria for this review. The majority (n=8) of the tools were selected from the results of Google Scholar searches.
PRISMA flow diagram for study selection. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.
Study characteristics
Table 1 displays the title, year of publication, source of recommendations and references for evidence levels and grades for seven articles identified from the search of all databases. The publication years ranged from 2015 to 2020 representing three countries (USA, UK and Canada) and one international guideline. Publication topics included VTE, antibiotic prophylaxis, as well as the broad-spectrum of peripartum care. For these articles, the content was either exclusively focused on the management of obesity or the content was about a high-risk condition during pregnancy and addressed obesity among other issues. Table 2 displays the topic, content of the recommendation, and evidence levels and grades for each recommendation from the seven articles in table 1. For the tools, table 3 displays the title, year of publication, source of recommendations and content topic for the peripartum management of obesity identified from searches of PubMed MEDLINE, Embase, Cochrane Central Register of Controlled Trials and CINAHL (n=3). Online supplemental appendix B displays the same information identified from a search of key websites and Google Scholar for tools (n=8). We found a wide range of tools including checklists, bundles, flow charts, guidelines, protocols, care pathways and care maps from practices in the USA, Canada and the UK.
Supplemental material
Source of recommendations, year of publication, title, evidence grading system and levels and grades for seven articles related to peripartum management of obesity
Topics, recommendations, and level or grade of evidence among seven articles related to peripartum management of obesity
Title, year of publication, source of recommendations, content topic and evidence to support recommendations among three tools related to the peripartum management of obesity
Synthesis of results
The evidence-rated recommendations covered topics such as labour induction (eg, indication and timing), intravenous access, fetal monitoring (eg, scalp electrodes, intrauterine pressure catheters IUPC), management of the first and third stages of labour, breast feeding and system-related preparedness. Several recommendations were specific to caesarean delivery (eg, incision type, antibiotic prophylaxis and dose, subcutaneous tissue closure, negative pressure dressings and VTE prophylaxis) and anaesthesia (eg, consultation, early placement of an epidural catheter). In several instances, recommendations for persons with obesity did not differ from recommendations for persons without obesity (eg, antibiotic prophylaxis for caesarean delivery).14 Three articles had one recommendation15–17 and the highest number of recommendations was 11 in a single article.18 The FIGO (International Federation of Gynecology and Obstetrics) Pregnancy and Non-Communicable Disease Committee published guidelines for the management of prepregnancy, pregnancy and postpartum obesity. Their recommendations for peripartum management (n=11) were included in this analysis, but it should be noted that the recommendations were not unique to the article, but instead they were abstracted from previously published international articles.18
The recommendations that were of the highest grade (strong, level 1 or grade A) were antibiotic prophylaxis for caesarean delivery,14 18 higher dosage of preoperative antibiotics for caesarean delivery16 19 and subcutaneous tissue closure.9 14 We noted that 13 recommendations were based on expert opinion or the lowest level of evidence. We noted that topics such as antibiotic prophylaxis (n=4 recommendations),16 18 19 subcutaneous skin closure (n=4 recommendations)9 14 19 and VTE prophylaxis (n=8 recommendations)9 15 18 19 were most commonly addressed. There were two instances where a particular intervention was not recommended (eg, subcutaneous drains, negative pressure dressing therapy).9 14 We did not find any recommendations that directly opposed one other, but there were differences in the specifics of the recommendations. For example, the American College of Obstetricians and Gynecologists recommends an anaesthesiology consult for persons with both obesity and obstructive sleep apnoea whereas the Royal College of Obstetricians and Gynaecologists (RCOG) recommends that the anaesthetist ‘be informed of all women with class III obesity’.9 14 In one guideline from the Society of Obstetricians and Gynaecologists of Canada (SOGC), the recommendation is for a ‘higher’ dose19 and another recommendation from the SOGC is for a ‘double dose’16 of antibiotic prophylaxis. Regarding specific recommendations for persons with different classes of obesity, we only found recommendations for weight-based VTE prophylaxis dosing9 15 17 and anaesthesiology consultations.14
Regarding the practical tools for implementation (table 3), the style varied. In a checklist and bundle, there were specific recommendations including ‘40 mg of enoxaparin subcutaneously two times per day for VTE prophylaxis after caesarean delivery’20 and ‘negative pressure wound therapy…applied in operating suite at the time of incision closure and left in situ for 7 days’, respectively.21 Another checklist had several recommendations for intrapartum and postpartum care with check boxes (eg, IUPC use, incision type, negative pressure dressing therapy), ultimately leaving the decision to perform the intervention or not up to the individual provider.22 Common terms found in the tools from Google Scholar searches included ‘consider’ a certain treatment option or ‘anticipate’ a particular complication (online supplemental appendix B). We noted differences in these tools for continuous fetal monitoring, where two tools recommend continuous fetal monitoring,23 24 but one did not.25 In addition, two tools21 26 recommended negative pressure dressing therapy for certain circumstances (eg, BMI >35 kg/m2 or >40 kg/m2) whereas another tool stated ‘avoid the use of wound vacs.’23
We then evaluated the similarities and differences between the evidence-rated recommendations in table 2 and any of the published tools in table 3. The evidence to support or not support the content in the tools from table 2 was provided in the last column of table 3. Some of the differences noted are as follows. The one recommendation in the checklist from the Society for Maternal-Fetal Medicine was supported from its own clinical series article.15 20 The recommendation from the bundle for prophylactic negative pressure wound therapy to reduce surgical site infection at a hospital in New South Wales, Australia was not supported by any recommendations in table 2.21 We observed that evidence-rated recommendations supported the majority of the content in the checklist from Abdelmalek et al. These included to notify anaesthesiology providers, have resources available to accommodate increased weight (eg, operating room equipment and blood pressure cuffs), give prophylactic anticoagulation (though dose adjustments not specified) and have a lactation consultation.22 However, content such as delay in staple removal or adjustments in postpartum pain management were not found in other evidence-rated recommendations in table 2.
Discussion
Principal findings
In our scoping review of the peripartum management of obesity, we found seven articles with evidence-rated recommendations. The articles included national guidelines from the FIGO (n=11 recommendations), USA (n=6 recommendations), UK (n=13 recommendations) and Canada (n=9 recommendations). The majority of the levels of evidence were second or third tier (Level 2 from Grades of Recommendations, Assessment, Development and Evaluation, Level II or III from Canadian Task Force on Preventive Health Care, or Grade B or C from US Preventive Services Task Force). The recommendation that was of the highest grade (strong, level 1 or grade A) was antibiotic prophylaxis for caesarean delivery,14 18 yet these recommendations apply to persons of all weights. A higher dosage of preoperative antibiotics for caesarean delivery also had the highest grade in one article19 as well as subcutaneous tissue closure.9 14 We noted that 13 recommendations were based on expert opinion, or the lowest level of evidence. We noted that the majority of these recommendations would be considered ‘low-risk’ interventions such as lactation and anaesthesia consults and developing a system or clinical care pathway for persons with obesity. Other expert opinion recommendations might be considered in the labour management for all persons depending on the clinical situation (eg, intravenous access, fetal heart rate monitoring and IUPC use).
Although we did not find directly opposing recommendations, there were subtle differences in some of the recommendations including criteria for anaesthesia consults and antibiotic dosing. There is considerable debate over appropriate prophylactic dosing of antibiotics for caesarean delivery in persons with obesity given that pharmacokinetic studies suggest improved or similar tissue concentrations with adjusted dosing,27–30 whereas a study comparing clinical outcomes such as surgical site infections did not demonstrate significant differences when comparing standard versus higher doses of antibiotics.31 The variations in recommendations may reflect the uncertainty of whether to reach a physiological target versus a clinical outcome.
We found that the recommendation for prophylactic negative pressure therapy in one tool contradicted the RCOGs’ recommendation regarding this practice (‘There is a lack of good-quality evidence to recommend the routine use of negative pressure dressing therapy…’).14 We acknowledge the content in the tools may be unique to a site depending on available resources at the time of peripartum care as well as historical practice patterns, cost, ease of use and risk/benefit ratio to maternal and fetal health. In the tools we reviewed, language such as ‘consider’ or ‘anticipate’ suggests that a concrete recommendation is not available and care needs to be individualised.
Strengths and limitations in relation to other studies
Other authors have published summaries of clinical guidelines, similar to the ones we identified. For example, a systematic review of guidelines available worldwide for the management of obesity in pregnancy found 32 clinical practice guidelines covering the domains of preconception care, care during pregnancy, diet and exercise during pregnancy, care immediately before, during and after delivery, and postpartum care.32 For delivery and postpartum care, those authors identified the following recommendations: (1) obesity alone not an indication for induction of labour, (2) early establishment of venous access during labour for women with a BMI >40 kg/m2, (3) allowing for a longer first stage of labour before performing a caesarean delivery for labour arrest and (4) active management of the third stage of labour. Recommendations pertaining to caesarean delivery included: (1) obesity alone not an indication for elective caesarean delivery, (2) need for adequate staffing and equipment for maternal weight >120 kg, (3) suturing subcutaneous tissue if >2 cm of depth, (4) use of mechanical thromboprophylaxis before and after caesarean delivery and (5) weight-based dosing of medication used to prevent VTE. Lastly, they also identified recommendations for breastfeeding support and lactation consultants. These recommendations were similar to the ones we identified from national guidelines in our scoping review.9 14 19
Several of the evidence-rated recommendations in table 2 supported the content in the 11 tools we identified. However, we also found content not supported by evidence-rated recommendations such as a peripherally inserted catheter for difficult intravenous access and delayed staple removal. We identified a randomised controlled non-inferiority trial of early (postoperative day 3) or delayed (between postoperative days 7 and 10) staple removal for transverse skin incisions in persons with a BMI ≥30 kg/m2.33 Although the study was stopped prior to reaching the targeted sample size, the occurrence of superficial wound dehiscence was 15.2% in the early and 11.5% in the delayed group (Relative Risk 1.3, 95% CI 0.7 to 2.4) and there were no other differences in the secondary outcomes of seroma, haematoma, surgical site infection or pain scores among the two groups. Since the available evidence regarding timing of staple removal is limited, other clinical and non-clinical characteristics such as provider and patient preference likely contribute to decisions about staple removal timing.
Strengths and limitations of this study
We acknowledge several limitations to our study. We may not have identified all articles with evidence-rated recommendations, especially since our search ended in December 2020 and more recent articles were not identified. However, our search of available published literature was thorough including a search of appropriate web sites. Sites may have practical implementation tools that they use in the short term or long term, but they may not be published or available in a more public domain. We identified clinical guidelines from other countries including Ireland and Australia,34 35 but they were not included in this review because they were not accompanied by evidence-rated recommendations. Although topics such as contraception and postpartum weight management are important in the postpartum care of persons with obesity, they were not specifically addressed in this review, which pertained to peripartum care in the immediate postpartum period. Obesity was typically defined according to a BMI ≥30.0 kg/m2, but in many instances the timing of the BMI was not provided (eg, prepregnancy vs at delivery). Some recommendations were specific to a particular BMI cut-off, but others pertained to obesity, in general, without specifying a BMI. Lastly, we did not include recommendations that were intended for patient education only in this review.
Meaning of the study
Based on this scoping review, we propose the following key content for a peripartum checklist or toolkit in table 4. This content is based on evidence ratings and ease of implementation. In summary, persons with obesity are at high risk for morbidity and mortality, with an abundance of risk occurring during the peripartum period. A few guidelines exist for the care of these persons and the evidence to support care is limited. Thus, there is a need for high-quality studies encompassing peripartum interventions.
Proposed key content for a peripartum checklist or toolkit for persons with obesity
Conclusion
The recommendations for peripartum care for persons with obesity are based on limited evidence and few practical tools for implementation exist. Future work should focus on developing practical tools based on high-quality studies.
Data availability statement
The protocol is available for review at https://doi.org/10.18131/g3-gyms-ww23https://doi.org/10.18131/g3-gyms-ww23. A full list of the sources and search strategies is outlined in online supplemental appendix A. The protocol is available for review at https://doi.org/10.18131/g3-gyms-ww23https://doi.org/10.18131/g3-gyms-ww23. A full list of the sources and search strategies is outlined in online supplemental appendix A. The remainder of the data are available on reasonable request (ie, articles reviewed via covidence system).
Ethics statements
Patient consent for publication
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Twitter @JackMPeace, @hipstermfm, @PalomaToledoMD
Contributors MAK designed the study protocol. LCO completed the database search of potential articles. MAK, IC, JP, AP and PT reviewed abstracts, decided on inclusion and exclusion criteria, and reviewed the full-text of included articles. All authors contributed to the synthesis of results. All authors acknowledged approval of the final version for publication. MK is the guarantor of the study.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.