Topics, recommendations, and level or grade of evidence among seven articles related to peripartum management of obesity
| Topic | Recommendation | Level or grade of evidence |
| Route of delivery | The decision for a woman with maternal obesity to give birth by planned caesarean section should involve a multidisciplinary approach, taking into consideration the individual woman’s comorbidities, antenatal complications and wishes.14 | Level 2-, C |
| Labour induction | Induction of labour is recommended at 41+0 weeks of gestation for women with a BMI ≥35 owing to their increased risk of intrauterine death.18 | Strong + + + |
| Elective induction of labour at term in obese women may reduce the chance of caesarean birth without increasing the risk of adverse outcomes.14 | Level 2+, B | |
| Where macrosomia is suspected, induction of labour may be considered. Parents should have a discussion about the options of induction of labour and expectant management.14 | Level 1+, B | |
| Fetal monitoring | Electronic fetal monitoring is recommended for women in active labour with a BMI ≥35. Intrauterine pressure catheters and fetal scalp electrodes may help.18 | Conditional + |
| III-B | |
| Labour management | Allowing a longer first stage of labour before performing caesarean delivery for labour arrest should be considered in obese women.9 | B, Level II-2,3 |
| Blood pressure monitoring | Where available, an appropriately sized blood pressure cuff should be used for measurements. The cuff size used at the earliest time point should be documented in the medical records.18 | Conditional ++ |
| Intravenous access | Establish venous access in early labour for women with a BMI≥40 and consider a second cannula.18 | Conditional + |
| Women with a BMI 40 kg/m2 or greater should have venous access established early in labour and consideration should be given to the siting of a second cannula.14 | Checkmark | |
| Regional anaesthesia | In the case of vaginal delivery for women with a BMI ≥40, early placement of an epidural catheter is advisable in the case of an emergency caesarean delivery.18 | Conditional + + |
| Antibiotic prophylaxis for caesarean delivery | Women with a BMI ≥30 having a caesarean delivery are at increased risk of wound infection and should receive prophylactic antibiotics at the time of surgery. Women with obesity may benefit from higher doses.18 | Strong + + + + |
| In patients with morbid obesity (BMI >35), doubling the antibiotic dose may be considered.16 | III-B | |
| Women with obesity may benefit from higher dosage of preoperative antibiotics for caesarean birth.19 | I-A | |
| Women with class one obesity or greater having a caesarean section are at increased risk of wound infection and should receive prophylactic antibiotics at the time of surgery.14 | Level 1++, A | |
| Incision type, skin closure for caesarean delivery | There is a paucity of high-quality evidence to support the use of one surgical approach over another. Surgical approaches should therefore follow NICE CG132 but clinicians may decide alternative approaches are merited depending on individual circumstances.14 | Checkmark |
| Subcutaneous tissue closure | It is recommended to reapproximate the subcutaneous tissue layers at the time of caesarean birth to reduce wound complications.19 | II-2A |
| Women undergoing caesarean section who have more than 2 cm subcutaneous fat should have suturing of the subcutaneous tissue space in order to reduce the risk of wound infection and wound separation.14 | Level 1++, A | |
| Subcutaneous drains increase the risk of postpartum caesarean wound complications and should not be used routinely.9 | Grade A, Level 1 | |
| There is a lack of good-quality evidence to recommend the routine use of negative pressure dressing therapy, barrier retractors and insertion of subcutaneous drains to reduce the risk of wound infection in obese women requiring caesarean sections.14 | Level 2- to 1+, B | |
| Haemorrhage | Active management of the third stage should be recommended to reduce the risk of postpartum haemorrhage.18 | Strong + + + |
| Although active management of the third stage of labour is advised for all women, the increased risk of PPH in those with a BMI greater than 30 kg/m2 makes this even more important.14 | Level 2++, A or Level 1++, B* | |
| VTE prophylaxis | Postoperative pharmacologic thromboprophylaxis should be prescribed based on maternal weight.18 | Conditional + + |
| Mechanical thromboprophylaxis is recommended before and after caesarean delivery. Where available, women with a BMI≥35 should be given graduated compression stockings, or other interventions such as sequential compression devices, after caesarean delivery until mobilisation, which should be encouraged early.18 | Conditional + + | |
| When pharmacologic thromboprophylaxis is needed in pregnant women with class III obesity, we suggest the use of intermediate doses of enoxaparin (for cesarean delivery).15 | 2C | |
| Postoperative thromboprophylaxis is recommended, at appropriate dosing for the given BMI, due to the greater risk of VTE following caesarean birth with women with obesity.19 | II-3 A | |
| All women with class three obesity (BMI greater than or equal to 40 kg/m2) should be considered for prophylactic LMWH in doses appropriate for their weight for 10 days after delivery.17 | D | |
| Women with two or more persisting risk factors listed in table 1 should be considered for LMWH in prophylactic doses appropriate for their weight for 10 days after delivery. One risk factor=BMI ≥30 kg/m2.17 | B | |
| Mechanical thromboprophylaxis is recommended before caesarean delivery, if possible, as well as after caesarean delivery.9 | B, Level II-3 | |
| Weight-based dosage for VTE thromboprophylaxis may be more effective than BMI-stratified dosage strategies in class III obese women after caesarean delivery.9 | B, Level II-3 | |
| Breast feeding | Obesity is associated with low breastfeeding initiation and maintenance. Women with obesity in early pregnancy should receive specialist advice on the benefits of breastfeeding and appropriate antenatal and postnatal support for breastfeeding initiation and maintenance.18 | Conditional + + |
| Women with obesity should be offered lactation support in the postpartum period.19 | III C | |
| Obesity is associated with low breastfeeding initiation and maintenance rates. Women with a booking BMI 30 kg/m2 or greater should receive appropriate specialist advice and support antenatally and postnatally regarding the benefits, initiation and maintenance of breastfeeding.14 | Checkmark, Level 1+ | |
| Anaesthesiology consult | Antenatal assessment with obstetric anaesthesia may assist in planning for safer birth for women with obesity.19 | III-A |
| The on-duty anaesthetist covering the labour ward should be informed of all women with class III obesity admitted to the labour ward for birth. This communication should be documented by the attending midwife in the notes.14 | Checkmark | |
| Consultation with anaesthesia service should be considered for obese pregnant women with OSA because they are at an increased risk of hypoxaemia, hypercapnia and sudden death.9 | C | |
| Systems | Where possible, healthcare facilities should have clearly defined pathways for the management of pregnant women with obesity. The adequacy of resources and equipment available should be considered when making decisions around care, especially for women with a BMI ≥40.18 | Conditional + |
| Obstetric team planning may be helpful for women with obesity to navigate the steps in antenatal, labour and delivery, and postnatal care.19 | III-3 A† |
*The recommendation is reports as ‘level 2++, A’ on page 26 of the document and also reported as ‘level 1++, B’ on pages 8 and 30 of the document.
†The recommendation is reported as ‘III-3 A’, though this level and grade of evidence is not defined in the Society of Obstetricians and Gynaecologists of Canada document.
BMI, body mass index; LMWH, low-molecular-weight heparin; NICE CG, National Institute for Health and Care Excellence Clinical Guidelines; OSA, obstructive sleep apnoea; PPH, postpartum haemorrhage; VTE, venous thromboembolism.