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Management of a Super-morbidly Obese Parturient Requiring Caesarean Delivery (Again!).

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Obesity: Unique Challenges at the Time of Cesarean Commitment

Submitted: November 28th, 2018 Reviewed: March 27th, 2019 Published: April 26th, 2019

DOI: 10.5772/intechopen.86085

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Abstract

The obesity epidemic has touched all aspects of obstetric care, including the practise of cesarean commitment. Obesity is an contained risk cistron for cesarean delivery, and the increased prevalence of obesity has contributed to the overall rising in primary cesarean delivery seen over the by few decades. Because of the frequent existence of co-morbidities such as hypertension and diabetes, obesity is a plausible contributor to rising maternal bloodshed. In addition, obese women who undergo both master and repeat cesarean delivery have a higher take chances to develop surgical and post-operative complications, including wound infection and thromboembolic events. Surgical complications increment steadily with increasing maternal weight. In this chapter, nosotros volition review the incidence and contributing factors that lead to cesarean delivery in obese patients, peri-operative complications, and strategies to reduce these risks in obese women undergoing cesarean delivery.

Keywords

  • cesarean commitment
  • obesity
  • super-obesity

1. Introduction

Cecelia presents for a routine new obstetric appointment for her second pregnancy. She has had 1 prior pregnancy, and does not place any health problems on her intake paperwork. However, she is markedly obese, and her weight is in excess of 500 pounds, more than than the average in-role calibration can mensurate. Acceptable understanding of risks and management strategies to mitigate her run a risk is needed to optimize the chances of a health pregnancy outcome.

The prevalence of obesity, defined as torso mass index (BMI) ≥ thirty kg/mii, and super-obesity (BMI ≥ l kg/m2) is on the rise in reproductive aged women. Pregnancy complications such equally gestational diabetes, preeclampsia, macrosomia, and stillbirth are more common in obese women than in normal weight patients. Many of these complications occur in a dose dependent fashion; the higher the BMI category, the more likely complications are to occur. The obese patient has both an increased risk for needing an indicated primary cesarean delivery, an increased adventure for peri-operative complications, and is at higher take chances for failed trial of labor afterwards cesarean commitment. The super-obese patient, in particular, presents a unique challenge to obstetricians planning and preparing for cesarean delivery.

In this chapter, nosotros will review the testify of surgical risk at the fourth dimension of cesarean delivery, direction options to reduce surgical risks, and applied considerations in performing a cesarean delivery in the obese parturient.

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2. Incidence of cesarean delivery in obese women

Estimates of primary cesarean commitment rates in obese patients undergoing trial of labor range from 23 to 49%, and increase with increasing maternal BMI (23–46% BMI ≥30 kg/thouii, thirty–47% BMI ≥ 40 kg/m2, 45–49% BMI ≥ 50 kg/mtwo) [1, 2, iii, 4, 5]. The about common indications for cesarean delivery are labor arrest (61%) and non-reassuring fetal status (28%) [one]. Pre-labor primary cesarean delivery likewise increases with increasing BMI grade [v].

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iii. Factors contributing to cesarean delivery in obese women

The reason for the increased incidence of cesarean delivery in obese women is likely multifactorial, and includes higher chances of macrosomia – and hence labor dystocia, disordered and dysfunctional labor patterns, and provider level responses or bias towards cesarean delivery [5].

The combination of obesity and macrosomia significantly increases the risk of cesarean commitment [6]. Both pre-pregnancy BMI category and gestational weight gain are independent contributors to the development of a large for gestational age or macrosomic babe [7, 8]. Obese women tend to have higher gestational weight gain, despite stricter weight gain recommendations, and hence larger nativity weight babies [7]. A large fetus, for obvious reasons, predisposes the mother to a protracted labor course and cephalopelvic disproportion leading to an indicated cesarean delivery. In add-on, fear of shoulder dystocia and neonatal brachial plexus injury, which occurs more ofttimes at delivery of obese women even with lower fetal birth weight, may influence the decision to proceed with cesarean commitment [9]. Because of the chances of fetal macrosomia with advancing gestational age, a strategy of elective consecration at term may aid to reduce the chances of macrosomia, and hence cesarean delivery. Elective consecration was non associated with an increased risk of cesarean delivery in women with BMI ≥ xl kg/m2 [x].

Obese women also have dysfunctional labor patterns [11]. Obese women are less probable to have spontaneous onset of labor, less likely to achieve vaginal birth following spontaneous labor, and have a college gamble of being exposed to oxytocin than non-obese women [12]. Obese women may require larger doses of oxytocin than their normal weight counterparts, especially when undergoing induction of labor [xiii]. The pathophysiology of the increased oxytocin requirements and protracted labor course is poorly understood, but may be due to decreased myometrial receptor expression, prostaglandin insensitivity, and dumb myocyte contractility [14]. The dysfunctional and apparently disrupted myometrial activity may contribute to why we meet more unplanned cesarean commitment in obese women.

Provider factors also may contribute to the increase chance of cesarean delivery in obese women [15]. Considering the determination-to-incision and decision-to-delivery time interval for emergency cesarean commitment is significantly college in obese women, a recommendation of cesarean commitment may be made earlier, in order to let adequate time for surgical grooming [xvi, 17]. The timing of intervention for non-reassuring fetal heart rate patterns likely contributes to increased unplanned cesarean delivery, as well every bit pre-labor cesarean deliveries [5, xviii]. Obese women with prior cesarean delivery are more likely to decline trial of labor after cesarean, which may exist due to individual counseling by obstetric providers [19].

Despite the fact that cesarean delivery is performed more often in obese women, it is still a riskier mode of delivery. Planned cesarean delivery, fifty-fifty in super-obese women (BMI ≥ 50 kg/m2) does not reduce maternal or neonatal morbidity [1].

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4. Surgical complications

Important peri-operative complications of cesarean delivery in obese women include wound complications (infection, wound separation), thromboembolic events, and agin neonatal complications. A history of iii or more prior cesarean deliveries further increases the chance of complications such as transfusion, depression one min Apgar score, and wound complications [xx]. The timing of repeat cesarean – unscheduled or planned – may also increase surgical and neonatal risks, especially since obese women are more probable to develop pregnancy complications prompting unscheduled echo cesarean commitment [21]. Other surgical risks, such as bowel, bladder, or ureteral injury, or broad ligament hematoma, appear to exist comparably exceptional in obese and super obese women like in normal and overweight women [22]. Super obesity likewise increases the chance of maternal ICU admission and length of hospitalization, which is largely driven by maternal co-morbid weather condition [23, 24].

4.1 Wound complications

Wound complications – separation and infection, occur in approximately 10% of obese women delivered by cesarean [20, 25, 26, 27]. The odds ratio for wound complication in obese women is 1.fourteen–one.65 times normal weight controls, when adjusted for many confounders [25]. In that location is a marked dose response for wound complications by increasing BMI category, with an odds ratio increase of up to 2.0 for every five-unit increase increment in BMI [28]. Chances of wound infection in super-obese women have been reported as high as 30% [29]. In probably the largest sample reported (38,229 women), wound complications occurred in fourteen% of women with BMI ≥ 45 kg/gii following cesarean delivery [25]. Wound separations in particular are seen more than oft in patients with super obesity [30].

An increment in operative time in women who are obese is as well dose dependent on BMI category [17, 27, 31]. Longer operative time is strongly correlated to post-operative infection, and may be a potential modifiable factor to reduce wound complication [32]. Other peri-operative and surgical strategies that may help prevent wound complications, such every bit pre-operative antibiotics, choice of skin incision, and wound closure type are reviewed in Section 4.4.

4.2 Thromboembolic events

Other than cesarean delivery, obesity is the about mutual gamble factor for a venous thromboembolic upshot (VTE) in pregnancy [33]. The classic Virchow's triad of hypercoagulability, endothelial injury, and stasis of claret menstruum leads to the well-established take chances of VTE during pregnancy. Obesity itself, regardless of mode of delivery, is a significant risk factor for VTE, with reported risks of 1.seven to v.3 (odds ratio) above normal weight controls [34, 35, 36, 37]. Obese meaning women have greater risk for pulmonary embolism than deep-vein thrombosis (DVT); the adjusted odds ratio for DVT is 4.4 (95% CI 1.6–11.ix) and for pulmonary embolism is 14.nine (95% CI three.0–74.8) [35]. Similar other complications, VTE has a dose–response relationship with increasing BMI category [38].

The verbal contribution of the combination of obesity and cesarean delivery to VTEs is difficult to quantify. Immobilization and high BMI have a multiplicative effect on risk for VTE [39]. It is very likely that obesity and cesarean commitment also have multiplicative effects on the take chances for VTE. Prevention of VTE during cesarean delivery is discussed in Section 6.five.

4.iii Neonatal outcomes

Neonatal outcomes also appear to be influenced by maternal obesity at cesarean delivery. Neonatal morbidity, including low 5-minute Apgar scores (<vii), umbilical cord arterial pH < seven.ii, base excess ≤viii mmol/L, and neonatal intensive care unit admissions are seen more often in obese women who undergo cesarean delivery. Hypotension during spinal anesthesia, and prolonged puncture fourth dimension for regional anesthesia is more pronounced in obese women, and has been shown to cause lower umbilical cord pH in obese women undergoing scheduled cesarean commitment [xl, 41]. Women who are super-obese at the time of delivery have a twenty% gamble of neonatal intensive care unit access [26]. There is a twofold odds increase of adverse neonatal result (low v min Apgar score, cardio-pulmonary resuscitation and ventilator support <24 h, neonatal injury, or transient tachypnea of the newborn, form 3, four intraventricular hemorrhage, necrotizing enterocolitis, seizure, respiratory distress syndrome, hypoxic ischemic encephalopathy, meconium aspiration, ventilator support >2 days, sepsis and/or neonatal death) in women with super obesity compared to their normal weight controls [42]. Despite the trend towards earlier cesarean commitment, the inherent delays and slower decision-to-incision and incision-to-delivery times involved in moving obese women to the delivery suite, and in getting the baby out when marked fetal distress is evident may contribute to agin neonatal outcomes in some cases [43]. However, planned cesarean commitment is not protective against these risks, and suggests an underlying poorly understood biologic etiology may be the source of the increase in adverse neonatal outcomes seen in obese women.

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v. Preparation for cesarean commitment in the obese patient

Performing a cesarean delivery, primary or repeat, in an obese patient poses certain challenges to the obstetrician and the operative team. These challenges are amplified in the super-obese patient, where maternal weight requires detail preparation for routine surgical problems, such as physical establish or space preparation, and informed consent.

5.ane Physical plant training

Infirmary equipment is often not designed for super-obese women. Operating tables, delivery beds, and even scales may accept an upper limit weight rating that is lower than the weight of a super obese woman [44]. It is reasonable for a labor and delivery hospital unit of measurement to set a sufficient number of rooms with the equipment needed to safely labor and deliver a super-obese women, based on the characteristics of the population they serve and the number of deliveries performed. Our institution maintains one room capable of laboring a patient in backlog of 500 pounds. The bed has a college weight rating and is wider, and has hydraulics to assist in mobility should a motility to the operating room be indicated. The room also has a lift on the ceiling to a higher place the labor bed, which has been instrumental for aiding the super-obese woman in positioning – for instance to lift a leg during placement of a Foley catheter. The room is stocked with equipment and supplies necessary to treat an obese patient.

Since obese women behave a higher risk for cesarean commitment and up to a fifty% hazard of emergency cesarean delivery, preparation of an operating room fifty-fifty when trial of labor is attempted is necessary [44, 45]. If a wide operating room bed is not available, two standard 50-cm width tables tin exist secured together [44, 46]. Transferring the patient from a labor and delivery bed to an operating tabular array and then back to a medical bed or gurney tin exist hard and lead to staff injury. Air-assisted mattresses tin be placed underneath obese patients to facilitate bed transfers (e.yard., Hovermatt®, HoverTech International, Bethlehem, PA, USA). Some of these mattresses can as well provide lateral turns to help position patients to prevent aortocaval pinch [47].

Applied considerations for preparation of the operating room for scheduled or emergency cesarean of an obese patient should exist part of labor and delivery policy. Supplies, such as extra-large blood force per unit area cuffs, clothing, and big pneumatic pinch devices should be bachelor. Consideration of acceptable surgical supplies including long instrument trays and attainable self-retaining retractors (see Department six.3), as well every bit pre-operative preparation for anesthetic assistants (run into Section 6.1) may meliorate patient safe [48]. A checklist for physical plant preparation for cesarean delivery in the obese patient is presented in Tabular array 1.

Labor and delivery room
Bariatric bed with frame and trapeze (motorized to meliorate mobility)
Bariatric chair
Hydraulic lift
Air assisted mattress
Continuous positive air pressure (CPAP) equipment
Large or actress-large blood force per unit area cuffs
Extra-big clothing (gowns, panties)
Extra-large pneumatic pinch devices
Actress-large wheelchairs (motorized to improve mobility)
Toilet to exceed 500 lb. capacity
Operating room
Bariatric operating table, or two standard fifty-cm width tables strapped together securely
Air assisted mattress
Large or extra-large claret pressure cuffs
Actress-big pneumatic pinch devices
Long instrument tray
Large OR strap
Long spinal needles
Hard airway cart
Emergency cricothyroidotomy kit
Glide scope
Laryngeal mask airway
Video guided laryngoscopes
Adhesive straps / Elastoplast tape for pannus management
Self-retaining retractors (Alexis-O cesarean, Doyen)

Table one.

Physical plant preparation checklist for labor and cesarean delivery in obese patients.

Nursing care requires particular attention to support the delivery of an obese patient. Nurses crave knowledge of how to use specialized equipment, how to adapt ergonomics to prevent staff and patient injury, and preparation for known risks in social club to safely treat obese patients undergoing planned or unplanned cesarean delivery [44, 48]. Information technology may even exist reasonable to increase nurse to patient ratios in some situations [48].

5.ii Informed consent

Informed consent for cesarean is best initiated well before the operative day, because of the known increment chance of cesarean in obese women, too as the detail risks described in section 4. Informed consent obtained during labor is known to be specially cursory, and information technology is unlikely that obstetricians are able to adequately counsel obese patients about their specific risks at time of cesarean delivery [49]. Lack of informed consent tin can reinforce a claim of medical malpractice [50]. Discussion that includes culturally sensitive and tailored review of the patients' beliefs about her weight may help improve the surroundings and her delivery experience, and perhaps even impact her health outcomes [51]. It may be reasonable to address and document informed consent during her routine obstetric care visits, and/or at time of admission to the hospital, well in advance of the actual surgery.

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6. Surgical considerations

Challenges facing the obstetric team exercise not stop at preparation. The performance of a safe cesarean delivery in an obese patient starts with adequate anesthesia, continues with adaptations of surgical technique, and concludes with optimization of mail-operative intendance.

6.ane Anesthetic considerations

Full general anesthesia, epidural anesthesia, and combined spinal-epidural anesthesia are all options for hurting control during cesarean delivery in the obese patient. The option of anesthetic largely depends on the indication for cesarean and the status of the fetus at fourth dimension of commitment.

Regional anesthesia puncture times for epidural and combined spinal-epidural may be prolonged in the obese patient, and may even contribute to delays in determination to delivery times seen in obese women [31, 52]. There is a college adventure of regional anesthesia failures needing conversion to general anesthesia, and a higher chance of high block during spinal anesthesia necessitating full general anesthesia in super obese women (BMI ≥ 50 kg/m2)) [31, 53]. Nonetheless, dose reductions for spinal anesthesia have non been proven beneficial in obese patients [54]. The obese patient is at risk for a higher number of punctures at time of spinal placement, simply due to spinal cord distance from skin [41, 55]. Ultrasound guided regional anesthesia placement has been shown to reduce number of punctures in obese women [56].

The take a chance of regional anesthesia has to exist balanced against the risks of general anesthesia in obese patients, which include an inherent difficult airway, trans-placental passage of paralytic or sedating medication, and longer incision to delivery times. Pregnancy itself increases the gamble of hard intubation, and obesity appears to multiply this risk – noted to exist equally high every bit 33% [57]. The obese patient is as well at risk for aspiration (especially if a hard intubation is encountered), too as before oxygen desaturation [58].

Surgical positioning with a maternal 10–15 caste left lateral tilt is very of import in obese women, as their pannus may compress the aorta or vena cava leading to hypotension [44]. Obese women likewise feel more relative hypotension during spinal anesthesia [40]. In addition, the displacement of the pannus to allow for the surgical incision tin increase the chance of respiratory distress [44].

half dozen.2 Selection of the surgical skin incision

In that location is insufficient evidence to conclude a particular skin incision is superior in the performance of a cesarean delivery in obese women. Diverse choices have been reported including vertical supra-umbilical, vertical or transverse infraumbilical, and the traditional Pfannenstiel with taping of the pannus if necessary, see Effigy one. Vertical incisions are associated with a higher gamble of vertical/classical uterine incision, but a lower chance of low 1 and v minute Apgar score in women with BMI ≥ forty kg/m2 [59, threescore]. A randomized feasibility trial of 91 women showed no deviation in clinical outcomes between Pfannenstiel and vertical skin incisions, and suggested a larger study would have a low take a chance of finding a difference [61].

Figure one.

Surgical skin incision choices. A – Pfannensteil, B – Supraumbilical, and C – Infraumbilical. The Pannus is elevated using record bilaterally on the upper abdomen with gentle cephalad traction and anchored to the operating table. Care must be taken when choosing a lower abdominal incision (A or B) to avert transecting the pannus.

Surgeon preferences lean towards a Pfannenstiel peel incision. A written report of surgeon preference of incision type on obese patients betwixt Pfannenstiel with or without taping of the Pannus, and vertical in both emergent and non-emergent cesarean commitment, showed the bulk preferred Pfannenstiel with taping of the pannus in both cases [62]. Women prioritize safe when it comes to choice of skin incision. A survey of women with BMI ≥ 40 kg/m2 showed that neonatal and maternal safety ranked higher in priority over corrective outcomes in selection of skin incision [63].

Since a superior skin incision has non been clearly shown, it seems reasonable to cull the skin incision based on clinical characteristics of the maternal habitus, and surgeon preference. If a low vertical, or high transverse skin incision is selected in patients with a pannus, care must be taken to ensure the pannus is not transected.

6.3 Surgical techniques unique to obese women

Barrier self-retaining retractors, such equally the Doyen or Alexis-O retractor shown in Effigy 2, may exist used to facilitate exposure and reduce the demand for boosted hands in surgery to provide retraction. This may be particularly helpful in women with a large pannus. The Claw and Doyen retractor appliance uses hooks and an adjustable chain to attach a retractor placed nether the pannus to a railing across the upper terminate of the operating tabular array. Care must exist used as the pannus is displaced on the maternal abdomen and may lead to hypotension and respiratory difficulties, especially if the patient is under regional anesthesia [64].

Figure two.

Hook and doyen apparatus to retract pannus. The doyen retractor is attached with chains and hooks to a lateral bar on the operating table. The doyen retractor is placed under the pannus to elevate information technology out of the surgeon's way.

Longer operative time leads to increased chance of maternal complications including increased claret loss, transfusion, prolonged hospitalization and wound infection [32]. Unfortunately, the very nature of performing a cesarean section in the obese patient necessitates a longer surgery. Surgical techniques associated with shorter operative time may reduce complications. Techniques that favor blunt instead of sharp dissection reduce operative time, such as a modified Misgav-Ladach technique (limited sharp dissection in favor of blunt expansion), blunt expansion of the uterine incision, and finger-assisted stretching technique, or FAST [65, 66, 67]. Standardized operative technique besides assist reduce operative time [68]. Though not studied in obese women specifically, barbed sutures for uterine closure are also associated with shorter operative times [69].

Bear witness suggests that closure of the subcutaneous tissue (if over 2–3 cm in depth) and avoidance of subcutaneous drains subtract the chance of wound complications in obese patients [70, 71, 72].

There is one known exception to the principle of reducing operative time to improve maternal outcomes. Subcuticular closure with suture reduces chances of wound complications, despite taking more time [73]. The pick of suture (4–0 vicryl or four–0 monocryl) did non have an consequence on wound complications in a randomized controlled trial with a large number (66%) of obese women [74].

half-dozen.4 Prevention of surgical site infections

Pre-operative antibiotic prophylaxis within 60 min and prior to skin incision has been associated with a significant reduction in surgical site infection in all women, regardless of their weight. However, the pharmacology of pre-operative antibiotics is altered in obese women. College doses of pre-operative antibiotics may be needed to prevent surgical site infection. Women with BMI ≥ xxx kg/m2 may need 3 1000 of pre-operative cefazolin to attain similar tissue concentrations of antibiotics as normal and overweight women [75, 76, 77]. The addition of a 48-h course of cephalexin and metronidazole in add-on to the pre-operative cephalosporin Iv prophylaxis has as well been shown to reduce the chance of mail service-operative surgical site infection (inside 30 days) in obese women [78].

The addition of azithromycin to standard antibody prophylaxis in women of all weight groups undergoing non-elective cesarean delivery has been proven to reduce wound infection [79]. Given the high run a risk of wound infection in obese patients, it may exist reasonable to add azithromycin to standard antibiotic prophylaxis, even in women undergoing elective scheduled cesarean delivery [71]. In our institution, the addition of azithromycin has reduced surgical site infections in a longitudinal accomplice quality improvement project (unpublished data).

Dissimilar types of pare incisions have not been definitively shown to reduce wound complications. Small studies have shown like gamble of wound complications in obese women with Pfannenstiel and vertical incisions, which is surprising given the moist and microbe rich surround that exists in the skin folds of the pannus [80]. A meta-analysis initially suggested vertical peel incisions may reduce run a risk of wound infection, but this article was subsequently redacted due to a miscalculation that favored Pfannenstiel for reducing risk of infection [81]. Evidence at present suggests no clinical difference in outcomes of women with BMI ≥ 40 kg/g2 who have either Pfannenstiel or vertical skin incisions [61].

Self-retaining retractors, unfortunately, accept too not been found to reduce surgical site infection [thirty, 82].

As mentioned in Section 6.iii, subcuticular closure with suture reduces chances of wound complications in obese women [73]. Skin closure with staples is associated with a higher run a risk of wound complication (infection, separation) in obese women within 6 weeks of delivery [83]. Notwithstanding, this effect did non persist in women with course Iii obesity (BMI ≥ 40 kg/grandii [84]. The use of staples may be considered in super-obese women.

Many surgeons identify prophylactic JP drains in the subcutaneous tissue of obese patients undergoing cesarean delivery, with the thought wound seromas and infection may be prevented. On a large multicenter randomized trial, obese women with subcutaneous drains had similar rates of wound complications as those with subcutaneous fat closure only [85]. Even so, more contempo studies advise that the subcutaneous tissue should exist closed if more than than two–3 cm deep, and subcutaneous drains should be avoided to prevent surgical site infections [lxx, 71, 72].

Rubber administration of negative force per unit area wound therapy (Wound V.A.C.®, Prevena™) in obese patients with a BMI ≥ 40 kg/kii is associated with a reduction in surgical site infections [86]. Super-obese women may benefit from prophylactic application of negative pressure wound dressings, but a systematic review and meta-assay suggests this strategy is non beneficial when cut offs for awarding are dropped to women with a BMI ≥ thirty kg/10002 [87].

Despite implementation of known show based measures to prevent surgical site infection (prophylactic antibiotics within 60 min prior to skin incision, chlorhexidine –booze for skin antisepsis with 3 min of drying fourth dimension earlier incision, closure of subcutaneous tissue if ≥ii cm depth, and subcuticular skin closure with suture), surgical site infection remains high in obese women [88].

half dozen.5 Prevention of venous thromboembolic events

Pneumatic pinch devices, heparin, and low molecular weight heparin (LMWH) have all been suggested as strategies to reduce VTE in obese women undergoing cesarean delivery. Recommendations from major societies on the strategies for prevention of venous thromboembolism in obese women undergoing cesarean delivery are in conflict [89]. The American Higher of Obstetricians and Gynecologists (ACOG), the American Higher of Chest Physicians (ACCP), and the Royal College of Obstetricians and Gynecologists (RCOG) all differ slightly in their published recommendations. ACOG suggests all women undergoing cesarean delivery should use post-partum pneumatic compression devices, but gives no additional specific recommendations regarding obesity [ninety, 91]. The ACCP suggests obesity is a small-scale gamble factor for VTE, and does non recommend post-partum pharmacoprophylaxis unless two minor run a risk factors are present [92]. In contrast, the RCOG suggests pharmacoprophylaxis should be administered to women with a BMI > 40 kg/10002 who undergo a cesarean in labor.

Given their college chance of mail-operative VTE, it seems prudent to apply at minimum pneumatic compression devices for VTE prophylaxis in obese women undergoing cesarean delivery, and has been found to be cost effective [93]. It seems reasonable to consider VTE pharmacoprophylaxis in women with BMI > xl kg/m2, though at that place is lack of evidence to strongly support this strategy [94]. It is every bit of import to consider that standard prophylactic doses may not be sufficient to reach adequate concentrations due to the pharmacokinetics of LMWH in obese persons. Weight-based dosing of enoxaparin (0.5 mg/kg q 12 h) for prevention of thromboembolism is more constructive than BMI-stratified dosing (BMI 40–59.9 received 40 mg enoxaparin q 12 h, BMI 60 received threescore mg q 12 h) in achieving adequate anti-Xa concentrations [95, 96, 97]. Table 2 shows a weight-based enoxaparin dosing strategy for obese women.

Weight (lb) Dose (mg)*
200–240 50
241-290 60
291–330 seventy
331–370 eighty
371–400 90
>400 100

Table 2.

Weight based enoxaparin dosing.

Administered every 12 h. Adapted from Overcash et al. [95].


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7. Determination

Cesarean commitment occurs more often in obese women, and increases both maternal and neonatal morbidity. Adequate planning and preparation is required to perform a prophylactic cesarean delivery in obese women, particularly in super-obese patients. Optimal, evidence-based practice includes:

  • Adequate physical plant preparation with attending to sufficient equipment, policy, and staff grooming;

  • Initiation of informed consent procedure during prenatal intendance visits or at fourth dimension of admission, well in accelerate of performance;

  • Anesthetic consideration and preparation for increased puncture fourth dimension, number of punctures, high blocks, and difficult/high risk intubation;

  • Option of skin incision and attending to surgical techniques;

  • Awarding of strategies to reduce post-operative wound complications; and

  • Consideration of risk for and techniques to reduce risk for venous thromboembolism.

Despite adequate preparation and attention to prophylaxis confronting known agin surgical outcomes, the obese patient volition have elevated risk above her normal weight counterpart. Prevention of obesity, and adequate weight loss prior to conception is ultimately the best protection against complications at the time of cesarean delivery in the obese patient.

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Acknowledgments

The authors acknowledge the artistry of Karen Skaret's illustrations included in this Chapter.

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Conflict of interest

The authors accept no conflicts of involvement to report.

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Kristina Roloff, Suzanne Cao, Camille Okekpe, Inessa Dombrovsky and Guillermo Valenzuela

Submitted: November 28th, 2018 Reviewed: March 27th, 2019 Published: April 26th, 2019

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